IntraUterine InseminationIntraUterine Insemination

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•Easy to perform

•Training is easy

•Less invasive

•Risks are minimal

•Quality control possible

•Costs are minimal

Advantage

Items Addressed

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• What is IUI.

•Indications.

•Effectiveness.

•Cost Effectiveness.

• Factors affecting success rate.

•Advantages and complications.

The rationale is bypassing the cervical-mucus barrier and increasing

the number of motile spermatozoa with a high proportion of normal forms at the site of fertilization.

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Semen Preparation Techniques

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-Swim up.

-Albumin

-Percoll

-Minipercoll

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The washing procedures are necessary to remove prostaglandins, infectious agents, antigenic proteins, non-motile spermatozoa, leucocytes and immature germ cells.

Timing of IUI• Basal Body Temperature

• LH Surge ( urine/serum)

• US

Sites of insemination

• Intrauterine (IUI)

• Intracervical (ICI)

Indications • Male factor subfertility• Unexplained infertility• Endometriosis.• Combined ovulatory and ♂ factor

infertility.• Cervical and immunological infertility• Sexual dysfunction infertility.

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In long standing infertility caused by reduced sperm quality

expectant treatment seems to be disappointing with a spontaneous

conception rate of only 2% per cycle.

Collins J A et al. Fertil Steril; 1995, 64:22-28

Male Factor Subfertility

5th centile 95%CI

Volume 1,5ml (1.4-1.7

P H 7.2

Motility 40% (38-42)

Progressive Non progressive Immotile

32% (31-34)

Vitality (intact membrane)

58% (55-63)

Count 15X106 12-16X10 6

Normal forms 4% (3-4)

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The lower reference limit for semen analysis

WHO Lab Manual of Human Semen 2010

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-Oligozoospermia (O)

-Asthenozoospermia (A)

-Tratozoospermia (T)

Male factor Infertility (OAT)

Male subfertility

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In male subfertility IUI with or without COH a pregnancy rate of 10-18% per cycle has

been reported.

-Stone BA et al 1999. Am. J Obstet Gynecol, 180:1522-1534

- Ombelet W et al 1995,Hum. Reprod. 10 (Suppl. 1):90-120

- Ombelet W et al 1997. Hum. Reprod. 12:1458-1463

Male subfertility

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A Cochrane review showed that IUI is superior to TI,

both in natural and in cycles with CoH.

Cohlen BJ et al 2000. (Cochrane Review)

Cochrane library, issue 4, update software, Oxford.

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(cumulative ongoing PR of 21.9% after three IUI cycles).

-Centole GM 1997. J. Androl; 18:448-453

Infertility work -up

No tubal factor

HSG, Laparoscopy, HSCS..

Washing procedure

IMC> 1 millionIMC< 1 million

IMC< 1 million

Morphology <5%

IVF

< 30 % or no fertilization

ICSI

IUI 4x

Proposed algorithm of male subfertility treatment at the Genk Institute for fertility Technology (ICM, insemination motile count of the number of motile spermatozoa after washing procedure; HSG, hysterisalpingography; HSCS, hysatero-salpingo-contrast-sonography)

Ombelet W et al 2008). ESHRE Monograph , 1: 64-72

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Meta –analysis comparing IUI and TI in natural cycles showed no difference

in results; therefore, IUI in natural cycles seems ineffective in case of

unexplained infertility.

Unexplained infertility

Cohen BJ. Gyn. Obst. Invest; 2005,59:3-13

Sexual Dysfunction infertility

• Retrograde ejaculation• Vaginismus• Hypospadius• Impotence• Infrequent Intercourse during fertile

period.

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ESHRE Capri Workshop Group

IUI in stimulated cycles may be considered while waiting for IVF or when in women with

patent tubes IVF is not affordable.

ESHRE - Hum Reprod. Update, 2009

Vol,15, No. 3, 265-277

Efficacy of IUI

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Intercourse in natural cycle

IUI in

natural cycle

Intercourse in stimulated cycle

IUI in stimulated cycle

Four comparisons to be performed in RCT to (dis) prove the efficacy of IUI with or without MOH

Cohen BJ and Tournaye H in Macklon NS et al (ed) informa healthcare 2008

Factors affecting IUI success

• Age of the female.• Natural cycle versus O.I• Number of IUI treatment cycles. • Site of insemination• Exact timing of IUI

Complications • Relatively low success rate / cycle.

• PID 0.01-0.2%.*

• MP

• Prematurity & low birth weight.**

* Dodson and Haney, 1991*Ombelet et al 1995**Wong et al 2002, Gaudoin et al 2003, Ombelet et al 2006.