Advantages of IUI

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Advantages of IUI

• Bipass (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
  pregnancies from normal S I)

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Disadvantages

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

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Success of IUI

• The review of literature over the past 15 years
• Take home baby

• wide range of variation
• 0-26 pregnancy / cycle in different indications
• Mansoura integrated Fertility Center ( MIFC)
  (18).
• Controversy No evidence- based infertility data.

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Indications for IUI-H

• Ejaculatory failure (Hypospadius- Vaginismus-
  Impotence- retrograde ej.)
• Cervical factor (mucus hostility-poor
  mucus)
• spont
  cycle protocol.
• Male subfertility (Mild, moderate)
• Immunological (Male sperm a.bs- female
  antisperm a.b)
• Unexplained.
• Husband is away from wife for long time (work
  abroad)

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Indications Cont...

• Endometriosis (mild).
• Ovulatory (?! Induction timed sexual I).
• Combined non tubal infertility factors.
• HIV negative women with processed semen of HIV
  ve husband.
• Cancer-husband cryopreservation of semen prior
  to chemo, radiotherapy or orchidectomy.

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Factors affecting success of IUI

• Couple
• (age,duration of infertility,cause of
  infertility.)
• Therapies
• Semen processing technique.
• Protocol of COH.

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Timed intercourse versus IUIProbability of
conception

• Natural cycles (IUI ?)
• COH cycles (IUI ? ? ?)
• ( cochrane database 2000)

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Questions remain to be answered (Evidence -
based fertility ???)

• Which type of couples with male subfertility
  benefit most from COH IUI

?
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Cont..
? ? ?

• Is IUI and /or COH cost effective for male
  subfertility compared with IVF? And for how many
  cycles?
• What is the threshold level for numbers of
  motile spermatozoa after sperm preparation beyond
  which treatment outcome is no longer improved? Or
  what is the minimum number of motile sperms below
  which IUI is no longer effective

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What is the Answer??Male subfertility

• Pre processing (mild or moderate), not severe.
• Count Motility
  Morphology
• Million/ml
  (G1G2) (N)
• Mild 15-20
  40-50 30-40
• Moderate 10-15
  20-40 10-30
• Severe lt10
  lt20 lt10
• Post processing inseminated motile sperms G1 gt
  1 million/ml.

WHO
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Pre-requisities

• Optimizing the office.
• Optimizing the knowledge.

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Pre-requisities cont.

• Optimizing the office for IUI
• 1. Organization of the practice to be extended in
  the week ends or holidays.
• 2. Availability of TVS probe.
• 3. Utilize remote semen preperation ( RSP )
• 4. Utilize remote folliculometry service.

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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.

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Pre-requisities cont.

• Optimizing The Knowledge For IUI
• The gynecologist should be aware of

• Indications
• Be sure that
• Women not have a concomitant condition that
  would prevent successful insemination.

2. Semen processing.
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Semen processing

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

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Techniques Semen processing

• Centrifugation (two step washing)(Wiltbank et
  al,1985).
• Swim-up (Sher et al,1984).
• Glass wool filteration (Jeyendran et al,1986).
• Per coll density gradient (Smith,1995).

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Pre-requisities cont.
Optimizing The Knowledge For IUI The
gynecologist should be aware of
3. IUI workup.
4. Different protocols of superovulation.
5. Prevention of complication of superovulation.
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Ovarian Stimulation Protocol

• Rationale for use COH
• Protocols commonly used

• -??Number of oocytes available
• -?Steroid production ?( chance of
  implantation )

• 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.

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Pre-requisities cont.

• Optimizing the Knowledge for IUI
• The gynecologist should be aware of

6. The optimal time for referral the case to an
infertility centers (The biological clock ticks
with every failed attempt for conception)
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Awareness of The Time of Referral To Infertility
Centers

• 1. Age gt 35 Y.
• 2. Failed 3 IUI.
• 3. Severe male subfertility.
• 4. Number of mature follicles gt4 (not give HCG).
• 5. Number of follicles (gt12 mm) gt8 (not give
  HCG).
• 6. Extensive endometriosis.
• 7. Need for cryopreservation of semen.

8. Non optimized office.
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Conclusions

• IUI is relatively simple, cheap, effective and
  is non-invasive method.
• Careful selection of patient is important.
• Young women with patent tubes, no ovulatory
  disorder, no moderate or severe endometriosis and
  no severe degree of male factor.

• Most who will benefit are

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Conclusion cont

• For practicing IUI as an office procedure
  pre-requisities regarding optimization of the
  office and knowledge of gynecologists should be
  present

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Conclusions cont

• Although IUI can be performed in an optimized
  office, but centers with IVF facilities offer the
  best setting, as there is a chance of
• Selective follicular reduction.
• Conversion to IVF.
• Freezing any extra embryos.

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Thank you
Prof. DR. MOHAMMAD EMAM
OB GYN, Mansoura Faculty of Medcine Mansoura
Integrated Fertility Center (MIFC) EGYPT Telfax
0020502319922 0020502312299 Email.
mae335_at_hotmail.com