MODERATOR :
Dr Shashwat Jani.M.S. ( Gynec ).
Diploma in Advanced Endoscopy ( France )Asst. Prof. , Smt. N.H.L. Municipal Medical College.
Sheth V.S. General Hospital, AhmedabadMobile : +91 99099 44160.
Email : [email protected]
OPTIMIZING SUCCESS IN IUI PANEL DISCUSSION
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Case Selection
What are Male and Female factors for IUI.? Indications for donor IUI?
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Male Factors…
Retrograde Ejaculation Impotence or Ejaculatory Dysfunction Hypospadias Hypospermia (Low Volume) Non Liquefying / highly viscous semen ‘Subnormal’ semen parameters Seminal Antisperm Antibody Unexplained Infertility.
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Female Factors…
Vaginismus Cervical Hostility Ovulatory Dysfunction Mild Endometriosis Allergy to seminal plasma Unexplained infertility
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Donor Semen IUI…
Azoospermia with testicular failure Severely abnormal semen parameters Use
Discretion) Hereditary disease in man Severe untreatable Rh isoimmunisation in
wife Repeated failures with IVF/ICSI Single women, lesbian couples (Use
Discretion)
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Ovulation Induction
Spontaneous.
Clomiphene
Clomiphene + Gonadotrophins
Gonadotrophins.
What are the Standard Protocols…???
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Some Protocols of Gonadotrophins…
Gonadotropins only
Gonadotropins with CC
Gonadotropins with GnRH analogs
Gonadotrophins with GnRH antagonists
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Gonadotrophins only
Standard protocol
Most commonly used
Started from day 3,4,5
Daily or alternate days
75 to 150 IU / day till hCG
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Advantages:
Direct action Dose dependent response Fine-tuning of dose possible No unwanted side effect Like - Ant estrogenic effect of CC
↑ risk of abortion with CC
↑ in LH with CC
↓ E2 at hCG as seen with Letrozole
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Disadvantages :
↑ Consumption
Vs. CC / Letrozole + gonadotropins
↑ OHSS
↑ Multiple pregnancy
↑ ↑ Cost
Injections only
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Gonadotropins with CC
Protocols : - CC followed by gonadotropins - CC + gonadotropins from day 3 Dose : CC 50 – 100 mg. / day for five days + 75 to 150 IU / day - Daily or alternate days Adv. - less dose Disadv. - Anti-estrogenic effect of CC - Poor control
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Gonadotrophins - Conclusions
Hypogonadotropic hypogonadism –
HMG is better as LH is required
Patients with high LH
A few PCO - FSH is better
Gonadotropins are must for stimulation in
down regulated patients
Adequate LH is required
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GnRH analogs :
Adv. : Effective Can prevent LH surge Choice of protocols
Dis. adv. : Additional medication ↑ Gonadotrophin dose ↑ Cycle cost ↑ Length of treatment
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GnRH Antagonists :
Occupy pituitary GnRH receptors Direct & immediate effect No flare response Immediate reversal Constant supply is must
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GnRH Antagonist :
Adv.: - ? ↓ Gonadotropin requirement - ? ↓ Duration of treatment - Can use GnRH agonist for LH surge - CC/ Letroze can be used
Disadv.: - Cost
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Sperm Preparation
What are the Standard Sperm Preparation Techniques…?
Effect of Sperm count in success of IUI.
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Principles of sperm preparation :
Remove : Seminal plasma and debris Pus cells, RBCs Prostaglandins Antigens
Separate best motile and morphologically normal sperm. Achieve Capacitation
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Methods …
1 ) Swim up technique :
Advantage : Recovery of best motile sperm Disadvantage : Loose many motile sperm
2 ) Density gradient technique:
Advantage: Maximum sperm recovered Disadvantage: A few non motile - dead sperm
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Effect of Sperm Count IN success :
Severe Male infertility < 5 million Moderate Male infertility <10 million Mild Male infertility 10 – 15 million
IUI success: Effect of sperm count More than 10 million +++ More than 5 million +++ 1 to 5 million ++ Less than 1 million ?
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Timing of Insemination :
Timing of hCG administration in CC / HMG / FSH cycle…???
Timing of IUI : - Pre Ovulatory - Post Ovulatory ( After 24 ,36 , 38 or 48 hours ? ) How many times ? - Single - Double.
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Timing of hCG administration :
With CC Cycle : Follicle size 20 -24 mmWith HMG Cycle : Follicle size 18 mm .
ET at least 8 mm.
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Timing of IUI :
Ideally 36 -38 after HCG administration
OR
After Confirmation of Ovulation.
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How many times … ???
In Literature, it has not been quoted when to do Double and when to do Single IUI.
Many papers suggest that Double IUI doesn’t increase the pregnancy rates.
The Cochrane review & NICE Guidelines also suggest that Double IUI adds to cost and inconvenience without improving efficacy.
Still some prefers… !!! ;-)
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Technique of IUI :
Position of patient ? Aseptic precaution? UCL , Position of uterus ? Which catheter : Soft or Rigid ? Catheter : Indian or Imported ? Location of Tip ? Abdominal USG Guided ? Quantity of sample ? Post IUI Rest ? Antibiotics ?
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Important points :
Measure UCL by USG at the time of baseline scan.
All aseptic precaution Don’t use antiseptics or saline. Lithotomy or Headlow Gentle atraumatic Insertion 0.4 – 0.8 ml sample Rest for 10 – 15 minutes. No need of antibiotic.
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Complications of IUI:
Very less likely problem is infection.
It may occur in 0.01% to 0.2% cases.
Allergy to some component in the media used
(Albumin, antibiotic etc) rarely occurs.
C.O.H. increases chance of multiple gestations.
C.O.H. even properly conducted has 1% chance of developing OHSS.
Miscarriage rate of 20-30% is slightly higher but not directly related to
IUI per se but the couples which get chosen for IUI.
3 to 5% ectopic pregnancy rate must ensure alertness on part of clinicians.
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Contraindications of IUI :
Blocked tubes, major tube pathology Genital tract infection in either wife or husband Severe abnormality in semen parameters (low
count < 5 million in pre-wash sample, asthenospermia, severe teratospermia)
Genetic reason for above poor semen parameters Wife’s advanced age. Multiple aetiologies /co-existing factors for
infertility. Multiple, previous failures of IUI.
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Difficult situations in IUI couples :
Husband unable to provide semen (tension, non erection etc) on
day of ovulation. Semen parameters very different from previous reports (should not
happen but episodes of fever etc can change count, motility. Poor
ejaculation may be result of tension on day of IUI) Cervix not negotiable, resulting in struggle & bleeding, which
simply harms any chance of success. (Be prepared beforehand –
proper OPD check up, SOS cervical dilation in previous visit,
proper measuring of utero cervical length & utero cervical
angulation at T.V.S. Unco-operative, grossly obese patient. Prior counseling helps here.
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Total No. of IUI Cycles …?
Female age < 35 years : Maximum 6 cycles.
Female age > 35 years :
Maximum 3 cycles then go for IVF…!!!???
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Success Rate :
What success rate for IUI can be quoted ? Limitations of IUI ? Why IUI fails.?
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What success rate cane be quoted ?
1. It depends on case selection indication, wife’s
age, motile sperm count, media & method used &
ease of catheter passage at insemination.
EVERYTHING MATTERS.
2. Success rate does not exceed natural fecundity
rate. Good units quote a success rate from 10% to
20% per cycle.
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3. At this rate it may touch 60% at end of 5-6 months & does not
increase thereafter. So if 6 good cycles & good inseminations have
not worked then review the diagnosis 7 indication.
4. Success in ‘natural’ cycle can be as low as 5% success with
Clomiphene/Letrozole climbs upto 7-10%. Adding HMG/FSH
along with Clomiphene can take success rate upto 20% per cycle.
Combination of oral medication with HMG does not lessen success
rate but cuts down total cost of HMG/FSH.
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Why IUI fails…???
• Poor semen preparation • Poor selection of patients • Improper egg pick-up by fimbria due to peritubal adhesions • Prevalence of empty follicle syndrome Or poor Oocyte quality.
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Limitations of IUI :
Hospital and lab distance. Proper maintenance of standard of Lab.Sperm requirement in millionsFertilization can not be assuredQuality of embryo unknown…
