WHEN TO MOVE FROM IUI TO IVF? Dr(Brig) R K Sharma VSM DIRECTOR HOD IRMIC

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WHEN TO MOVE FROM IUI TO IVF?Dr(Bri
g) R K Sharma VSMDIRECTOR HODIRMIC
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IUI

• Effective , non invasive, relatively simple
  inexpensive method of treatment.
• Can be provided easily in simple setups.

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INDICATIONS OF IUI

• Mild to moderate Endometriosis
• Unexplained infertility
• Anovulatory infertility
• Cervical infertility
• Immunological abnormalities
• Mild degrees of male factor infertility
• Non-consummation of marriage due to
  ED/vaginismus

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PRE REQUISITES FOR IUI

• Atleast one patent functional tube
• Evidence of ovulation
• Adequate sperm count
• Responsive endometrium

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Approximate chance for success getting pregnant
with one month of various treatmentsFemale age
under 35, 2 years of trying to conceive
Type of Treatment Total Motile Sperm Count (in millions) Total Motile Sperm Count (in millions) Total Motile Sperm Count (in millions) Total Motile Sperm Count (in millions) Total Motile Sperm Count (in millions)
Type of Treatment Less than 1 1-5 5-10 10-20 gt 20
Intercourse 0.2 1 2 2.5 3
IUI 0.4 2 4 5 7
Clomid plus IUI 0.5 2.5 5 7 9
FSH plus IUI 0.5 2.5 6 9 12
In Vitro Fertilization - IVF with ICSI 40 40 40 40 40
IVF results depend upon the clinic
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THE IMPACT OF THE TOTAL MOTILE SPERM COUNT
Total motile sperm count
Pregnant group 38.7 x 106
Non pregnant group 28.6 x 106
Significance was reached when the total motile
sperm count exceeded 5 x 106.

• The impact of the total motile sperm count on the
  success of intrauterine insemination with
  husband's spermatozoa. Huang HY, et al. J Assist
  Reprod Genet 13 1, 56-63, Jan, 1996

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THE IMPACT OF THE TOTAL MOTILE SPERM COUNT

• An average total motile sperm count of 10x106 may
  be a useful threshold value for decisions about
  treating a couple with IUI or IVF.

Effect of the total motile sperm count on the
efficacy and cost-effectiveness of intrauterine
insemination and in vitro fertilization. Van
Voorhis BJ, et al. Fertil Steril 2001
Apr75(4)661-8
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SPERM QUALITY NECESSARY FOR SUCCESSFUL
INTRAUTERINE INSEMINATION

• Initial sperm motility ?? 30
• The total motile sperm count ? 5 X 106.
• When initial values are lower, IUI has little
  chance of success

Comparison of the sperm quality necessary for
successful intrauterine insemination with World
Health Organization threshold values for normal
sperm. Dickey RP, et al. Fertil Steril 1999
Apr71(4)684-9
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IMPACT OF SPERM MORPHOLOGY

• Patients with more than 60 normal sperm
  morphology (NSM) had higher pregnancy rate than
  those with less than 60 NSM (24.3 vs. 7.7,
  P0.0052).

Intrauterine insemination pregnancy rate and its
associated factors in a university hospital in
Iran Zahra Rezaie, et al. Middle East Fertility
Society Journal,Vol. 11, No. 1, 2006, pp.59-63
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ADVANCED SEMEN ANALYSIS - HIGHLY PREDICTIVE OF
IUI SUCCESS

• The number of motile normal sperm available
  for insemination
• 24-hour survival rate.

Advanced semen analysis a simple screening test
to predict intrauterine insemination success.
Branigan EF, et al. Fertil Steril 1999
Mar71(3)547-51
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SPERM-PREPARATION TECHNIQUES- IUI RESULTS

• Abnormal semen analyses.
• Density gradient is superior to the swim-up
  technique in improving AR, HOS and nuclear
  maturity rates.
• Normal semen analyses.
• When only nuclear maturity rate is taken into
  account, the swim-up technique seems to be
  sufficient for selecting spermatozoa.

Sperm-preparation techniques for men with normal
and abnormal semen analysis.- A comparison. Erel
CT, et al. J Reprod Med 2000 Nov45(11)917-22
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IMPACT OF NUMBER OF IUI PER CYCLE

• Pregnancy rate significantly higher with
  increasing the number of IUI per cycles, being
  24.1 and 11.8 in two IUI per cycles and one IUI
  per cycle respectively

Intrauterine insemination pregnancy rate and its
associated factors in a university hospital in
Iran Zahra Rezaie, et al. Middle East Fertility
Society Journal,Vol. 11, No. 1, 2006, pp.59-63
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Single iui better cochrene 2009
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IMPACT OF INFERTILITY DURATION ON IUI RESULTS

• Pregnancy rate decreased with increasing
  infertility duration.

Zhao Y, et al. Impact of semen characteristics on
the success of intrauterine insemination. J
Assist Reprod Genet. 2004 May 21(5) 143-8
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Age and number of eggs
Faddy et al., 1992
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2005 CDC IVF Report Impact of advancing female
age on IVF success
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IMPACT OF IUI ATTEMPTS

• Most pregnancies in the first 3 attempts
• IUI treatment is not usually recommended for more
  than a maximum of 4-6 cycles
• If the reason for infertility is anovulation, it
  may be more reasonable to try several more cycles
  (6-9 cycles total).

Plosker SM, et al. Predicting and optimizing
success in an intra-uterine insemination
programme. Hum Reprod. 1994 Nov
9(11) 2014-21
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CC / OVARIAN CANCER

• Incidence of ovarian cancer in women taking CC
  was about three times greater than the expected
  incidence for the general population.
• Rossing MA, et al. Ovarian tumours in a cohort of
  infertile women. N Engl J Med 1994331771776
• . 

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CC / OVARIAN CANCER

• No significant difference between the observed
  incidence of ovarian cancer in women treated with
  CC and the expected incidence in the general
  population
• Venn A, Watson L, Bruinsma F, et al. Risk of
  cancer after use of fertility drugs with in-vitro
  fertilisation. Lancet 199935415861590.
• Parazzini F, Negri E, La Vecchia C, et al.
  Treatment for infertility and risk of invasive
  epithelial ovarian cancer. Hum Reprod
  19971221592161. 
• Mosgaard BJ, Lidegaard O, Kjaer SK, et al.
  Infertility, fertility drugs, and invasive
  ovarian cancer a case-control study. Fertil
  Steril 19976710051012. 
• Shushan A, Paltiel O, Iscovich J, et al. Human
  menopausal gonadotrophin and the risk of
  epithelial ovarian cancer. Fertil Steril
  1996651318. 

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CAUTION

• Prolonged use of clomiphene citrate may be
  associated with an increased risk of a borderline
  or invasive ovarian tumour.

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SPECIAL SITUATIONS

• Evidence of impending OHSS during IUI
• Add antagonist and convert to IVF

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RISK FACTORS FOR POOR OUTCOME WITH IUI

• Advanced female age
• Poor postwash sperm motility
• History of corrective pelvic surgery
• Poor postwash sperm motility in combination with
  either of these other two risk factors resulted
  in no successful pregnancies

The effect of patient and semen characteristics
on live birth rates following intrauterine
insemination A Retrospective study HENDIN B.
N.et al. Journal of assisted reproduction and
genetics  2000, vol. 17, no5, pp. 245-252 
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Sperm DNA fragmentation decreases the pregnancy
rate inan assisted reproductive technique

• Mehdi Benchaib et al.Reproduction Vol.18, No.5
  pp. 10231028, 2003

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Patient may have normal semenology and have high
DFI (DNA fragmentation index) or a very poor
count and motility ,yet betterDFI.
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Many cases of unexplained infertility who are
unable to conceive by IUI,IVF/ICSI can do better
after treatment of causative factors of abnormal
DFI or by testicular extraction of sperm
andICSI
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NOW REASONS FOR THE CLINICIAN TO MOVE FROM IUI TO
IVF
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• WHEN MORE THAN 05 IUI CASE MONTH
• 400 CASES OF IVF/YEAR-COST EFFECTIVE

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WHEN YOU WANT TO BE DIFFERENT
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When you get information that your competitor is
planning to open an IVF Centre
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When you are able to fish an embryologist from
others pond
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IMPORTANT

• Each centre should define its policy which takes
  into account
• Diagnostic laboratory techniques available,
• Selection of the SPERM PREP technique
• Pregnany rates achieved
• Sensibility of the treated population
• Health care characteristics

DECIDE -WHEN TO MOVE FROM IUI TO IVF?
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THANK YOU
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• HAPPY ANNIVERSARY
• ART CENTRE AIIMS

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