intrauterine insemination. aboubakr elnashar

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Benha Univresity hospital Email: [email protected] In Portugal ABOUBAKR ELNASHAR

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Page 1: Intrauterine insemination. Aboubakr Elnashar

Benha Univresity hospital

Email: [email protected]

In Portugal

ABOUBAKR ELNASHAR

Page 2: Intrauterine insemination. Aboubakr Elnashar

Direct transfer of

processed semen into the uterine cavity

about the time of ovulation

1. DEFINE

ABOUBAKR ELNASHAR

Page 3: Intrauterine insemination. Aboubakr Elnashar

2. RATIONALE

A. Direct transfer:

1. 3 of the natural barriers (vagina, cervical mucus,

and cervix) that sperm have to traverse are

bypassed.

2. More sperm are placed closer to the site of

fertilization (fertilization occurs in the fallopian

tube).

B. Processed semen:

1. Washing organisms, prostaglandins& antibodies

2. Deposition of a bolus of concentrated, motile,

morphologically normal spermABOUBAKR ELNASHAR

Page 4: Intrauterine insemination. Aboubakr Elnashar

ADVANTAGES OF IUI

1. Non invasive (like pap smear).

2. Inexpensive.

3. Easy to perform

4. Training is easy

5. Risks are minimal

6. Antenatal & perinatal complications:

like pregnancies from normal S I

ABOUBAKR ELNASHAR

Page 5: Intrauterine insemination. Aboubakr Elnashar

3. INDICATIONS

A.Male:

I. Ejaculatory failure:Retrograde ejaculationHypospadiusImpotenceInfrequent Intercourse during fertile period.

ABOUBAKR ELNASHAR

Page 6: Intrauterine insemination. Aboubakr Elnashar

II. Male subfertility: Mild

Severe male infertility:

Count<5million/ml (15million/ml)

Normal morphology <2% (4%)or

Motility <10% (40%)

Not candidate for IUI but ICSI.

According to the WHO criteria, the diagnosis of mild

male infertility problem is made when two or more

semen analysis results show one or more variables

below the fifth centile.

ABOUBAKR ELNASHAR

Page 7: Intrauterine insemination. Aboubakr Elnashar

After processing:

Insemination motile count (IMC) and sperm

morphology

(Ombelet et al 2003, 2008; Duran et al , 2002. SR; Butcher et al, 2016)

Most valuable parameters to predict IUI outcome

There is a trend towards increasing conception

rates with increasing IMC

lower limit

3 million motile sperm

(Strandell et al., 2003),

ABOUBAKR ELNASHAR

Page 8: Intrauterine insemination. Aboubakr Elnashar

Infertility work -up

No tubal factor

Washing procedure

IMC> 1 million

IMC< 1 million

Morphology >2IMC< 1 million

Morphology <2%

IVF

< 30 % or no fertilization

ICSI

IUI 4x

(Modified from Ombelet et al 2008. ESHRE Monograph) ABOUBAKR ELNASHAR

Page 9: Intrauterine insemination. Aboubakr Elnashar

Semen analysis: WHO, 2010

:

:Lower reference limitParameter

1.5 ml Volume

7.2 pH

15 million/ml Concentration

39 million/ejaculate Total sperm number

40% or 32%

Total motility: (PR+NP)

PR (a+b)

58% live spermatozoa Vitality

4% (strict criteria).Normal formsABOUBAKR ELNASHAR

Page 10: Intrauterine insemination. Aboubakr Elnashar

Abnormal semen

ICSI

TT of varicocele if palpable

Hormonal tt if low FSH &Testost.

Treatment of infection ?

Mild:≥2 NM, ≥5M, ≥10%TM Severe or

Azoospermia

3 trial IUI

ABOUBAKR ELNASHAR

Page 11: Intrauterine insemination. Aboubakr Elnashar

B. Female:

I. Cervical factor:

cervical mucous hostility, poor cervical mucous

significant improvement of conception for IUI compared

with TI

(Cohlen;2005, MA of RCT)

II. Endometriosis:

mild & moderate

IUI with OS, instead of EM: increases LBR(Tummon et al., 1997; ESHRE, 2009)

IUI with OS within 6 months after surgical tt,

PR are similar to those achieved in un infertility (Werbrouck et al., 2006; ESHRE, 2009)

III. Vaginismus

ABOUBAKR ELNASHAR

Page 12: Intrauterine insemination. Aboubakr Elnashar

C. Both:

I. Immunological:

Male antisperm antibodies

Female antisperm antibodies (cervical, serum)

II. Unexplained infertilityspermiogram is normal with normal female factor.

(Hajder et al, 2016)

III. While waiting for IVF

IV. women with patent tubes and IVF is not

affordable.

ABOUBAKR ELNASHAR

Page 13: Intrauterine insemination. Aboubakr Elnashar

4. CONTRAINDICATIONS1. Cervical atresia

2. Cervicitis

3. Endometritis

4. Bilateral tubal obstruction

5. Most cases of amenorrhea

6. Severe oligospermia.

ABOUBAKR ELNASHAR

Page 14: Intrauterine insemination. Aboubakr Elnashar

5. STEPSI. SELECTION & COUNSELING

II. OVARIAN STIMULATION

III. MONITORING OF

FOLLICULAR GROWTH &

ENDOMETRIAL DEVELOPMENT

IV. TIMING OF INSEMINATION

V. SPERM PREPARATION

VI. INSEMINATION

ABOUBAKR ELNASHAR

Page 15: Intrauterine insemination. Aboubakr Elnashar

I. SELECTION1. Basic investigations of infertility:

Semen analysis

Midluteal progestrone

HSG

2. Baseline ultrasound

3. Ovarian reserve Tests

Indications.

ABOUBAKR ELNASHAR

Page 16: Intrauterine insemination. Aboubakr Elnashar

COUNSELING Confidence of husband.

Cost

Complications.

Steps

Success rate: 15–20 % / cycle

Couple question & answer information:

increase effectiveness & promote +ve self

approach.

ABOUBAKR ELNASHAR

Page 17: Intrauterine insemination. Aboubakr Elnashar

II. OVARIAN STIMULATION

Rationale:

1. To increase the number of oocyte available

(< 4 mature follicles) for insemination & thus the

chance of implantation

2. To increase steroid production which may improve

the chance of fertilization & embryo implantation.

Disadvantages:

1. OHSS

2. Multiple pregnancy

3. Cost of drugs & monitoring. ABOUBAKR ELNASHAR

Page 18: Intrauterine insemination. Aboubakr Elnashar

III. MONITORING:

1. Follicular growth &

2. Endometrial development

Baseline U/S:

AFC

To exclude ovarian cysts

D3 FSH & LH:

Elevated LH & FSH: poor follicular response.

Raised LH/FSH: PCOS: excessive response.

From D8 of stimulation: serial U/SABOUBAKR ELNASHAR

Page 19: Intrauterine insemination. Aboubakr Elnashar

IV. TIMING OF INSEMINATION

1. US

2. Urine LH surge

Rationale:

• Viable spermatozoa should be present in the female genital system at the time of ovulation.

• Sperms retain their fertilizing capacity for 40-80 h

• oocyte have life span of 12-24 h after ovulation.

ABOUBAKR ELNASHAR

Page 20: Intrauterine insemination. Aboubakr Elnashar

Methods for timing of ovulation:

1. Urinary LH surge:

Serum LH surge (+12 h)

Urine LH surge (serum LH peak) (+24 h)

Follicular rupture

IUI 36 h after positive urine test .

ABOUBAKR ELNASHAR

Page 21: Intrauterine insemination. Aboubakr Elnashar

2. U/S folliculometry:

• The exogenous HCG mimics the endogenous LH surge &offers the advantages that the onset of LH surge is knownprecisely.

• HCG is given when the leading follicle is 17-20 mm.

• HCG should be withheld if

1. The number of mature follicles > 4 or

2. Number of follicles > 12 mm > 8

ABOUBAKR ELNASHAR

Page 22: Intrauterine insemination. Aboubakr Elnashar

No evidence of a difference in LBR between

hCG injection vs LH surge

urinary hCG vs rec hCG or

hCG vs GnRHa

Optimum time interval from hCG injection to IUI:

24 h to 48 h.

No difference in LBR

Choice should be based on

1. hospital facilities,

2. convenience for the patient, medical staff,

3. costs and dropout levels[Cochrane SR , 2014].

ABOUBAKR ELNASHAR

Page 23: Intrauterine insemination. Aboubakr Elnashar

Number of inseminations:

• One insemination performed

34-38 h after HCG or

24-36 h after urine LH surge

• The next day after HCG

(Egyptian fertility center)

• 2 inseminations performed:

24 & 48 h after HCG.

12 & 34 h after HCG

(Rangi et al,1999).

ABOUBAKR ELNASHAR

Page 24: Intrauterine insemination. Aboubakr Elnashar

V. SPERM PREPARATION1. Swim up method

2. Density gradient centrifugation.’ (DGC)

Collection of semen:

1. Sperm is obtained by masturbation into a sterile container

after 3-5 days of sexual abstinence.

2. Avoidance of lubricantsmost are toxic to sperm.

If a lubricant is needed, instruct the client to prevent contact

between the lubricant and glans.

ABOUBAKR ELNASHAR

Page 25: Intrauterine insemination. Aboubakr Elnashar

Selection of the method:

1. Normozoospermia:

Swim up

simple & quick way of producing a purified inseminate

containing a high percentage of progressively motile

spermatozoa.

2. Sperm disorders: (OAT):

DGC: superior to swim up technique.

3. High leukocyte concentration (>1x107/ml):

Swim up from semen,

DGC (sperm wash only after cell separation)

ABOUBAKR ELNASHAR

Page 26: Intrauterine insemination. Aboubakr Elnashar

VI. INSEMINATION

Equipment

Speculum

1 cc sterile syringe with blunt cannula

Disposable polyethylene insemination catheter

Two types of catheters

1. Relatively rigid single sheath catheters

(straight or with a preformed curve) that

cannot be bent

2. Double sheath catheters with an external

flexible sheath that will maintain a curve and

a very soft internal catheter.

PR and LBR:

same for flexible and rigid catheters

ABOUBAKR ELNASHAR

Page 27: Intrauterine insemination. Aboubakr Elnashar

Selection of catheter:

1. Soft flexible catheter can be formed to accommodate the curve of the

patient's uterus

less traumatic to the endometrium.

patients barely feel the IUI procedure

2. An internal wire or rigid stylet

may be used with the external sheath for difficult

IUIs.

3. Stiffer catheters easier to insert into the uterine cavity

do not bend

more

uncomfortable for the patient

traumatic to the endometrium

vaginal bleedingABOUBAKR ELNASHAR

Page 28: Intrauterine insemination. Aboubakr Elnashar

ABOUBAKR ELNASHAR

Page 29: Intrauterine insemination. Aboubakr Elnashar

Precautions:

1. Aseptic technique to avoid infection

Povidone iodine should not be used to cleanse the

cervix toxic to sperm

Antibiotic prophylaxis is unnecessary.

2. Gentle technique to avoid trauma of the

endometrium:

cramping & bleeding:

adversely affect the survival of spermatozoa

ABOUBAKR ELNASHAR

Page 30: Intrauterine insemination. Aboubakr Elnashar

Standard technique:

1. Ask women with AVF uterus to maintain a full

bladder

facilitate straightening of the uterus.

not useful for women with RVF uteri.

2. Lithotomy position

3. The cervix is exposed with bivalve speculum &

rinsed with saline

ABOUBAKR ELNASHAR

Page 31: Intrauterine insemination. Aboubakr Elnashar

4. The catheter is firmly connected to the cone of 1cc

tuberculin syringe

Plunger is withdrawn slightly& the sperm

suspension is then aspirated from the test tube

into the catheter without any air bubbles

Sperm is suspended in a small volume of media,

no more than 0.5 mL

prevent expulsion or reflux from the cervix and

uterine contractions after it is inseminated into

uterus.

ABOUBAKR ELNASHAR

Page 32: Intrauterine insemination. Aboubakr Elnashar

5. The catheter tip is advanced to a depth of

approximately 6 to 6.5 cm.

Try not to let the catheter touch the fundus

cramping and, in some cases, disruption of the

endometrium and bleeding: toxic to embryo

development.

ABOUBAKR ELNASHAR

Page 33: Intrauterine insemination. Aboubakr Elnashar

6. If difficulty is encountered with insertion of the catheter

use of a rigid stylet

abdominal US guidance

avoid use of a tenaculumuterine contractions and patient discomfort.

If catheter passage through the cervix is difficult:

grasp the cervix with tenaculum to straighten the

utero-cervical angle by gentle traction

ABOUBAKR ELNASHAR

Page 34: Intrauterine insemination. Aboubakr Elnashar

7. Inject the sperm

Leave the catheter in place for short time

withdraw it slowly avoid suction effect & prevent reflux.

Sperm are present in the fallopian tubes as early as 5

min after insemination

8. Patients rest in

supine or

reverse Trendelenburg position for 10 min

higher PR in rested patients compared with those

who were immediately mobile post IUI

(PR 25% vs 10%).

ABOUBAKR ELNASHAR

Page 35: Intrauterine insemination. Aboubakr Elnashar

Postprocedure care

The patient may resume her normal activities after

insemination.

Increased wetness after the procedure

Loosened and watery cervical mucus

does not mean the sperm specimen has flowed

out

patients should be reassured about this.

Abdominal cramping or discomfort may;

acetaminophen

Light bleeding or spotting

ABOUBAKR ELNASHAR

Page 36: Intrauterine insemination. Aboubakr Elnashar

Intercourse

within 12-18 h If they wish to do so

Pelvic discomfort

ovarian enlargement from CC or Gnt:

No intercourse.

A urinary or serum pregnancy test

2 w after IUI.

If the patient has received hCG for ovulatorytriggering, it is important to inform the patient that a urinary or serum pregnancy test may remain positive up to 12 days after the injection.

ABOUBAKR ELNASHAR

Page 37: Intrauterine insemination. Aboubakr Elnashar

LPS:

Vaginal progesterone

after ovulation induction/IUI:

higher LBR with compared with no

progesterone support (SR of RCT)

Benefit was restricted to

Gnt stimulated cycles.

history of unexplained RPL

luteal phase <10 days.

ABOUBAKR ELNASHAR

Page 38: Intrauterine insemination. Aboubakr Elnashar

Oral dydrogestrone

effective as vaginal progesterone for LPS

mean serum progesterone levels and satisfaction rates in dydrogestrone group were higher than cyclogest group.(Khosravi et al, 2015)

No difference

in PR and LBR per cycle and per patient

according to the use of LPS in IUI cycles using

gonadotropins.(Aytac et al, 2016)

ABOUBAKR ELNASHAR

Page 39: Intrauterine insemination. Aboubakr Elnashar

6. COMPLICATIONS

1. Uterine contraction

2. Intrauterine infection

Upper genital tract infection is a rare

PID: 0.01-0.2%

3. Psychological:

guilt, anger, loss of self esteem

Relatively low success rate / cycle.

ABOUBAKR ELNASHAR

Page 40: Intrauterine insemination. Aboubakr Elnashar

4. Complications of COH:

Multiple pregnancy.

increased with

age < 30

6 mature follicles

E2 > 1000 pg/ml

Gnt.

risk is much lower with CC.

MP (7-13%) (Ombelet et al 2006).

OHSS

only observed in exogenous Gnt cycles following

administration of hCG or after GnRHa

rarely occurs in women treated with CC

ABOUBAKR ELNASHAR

Page 41: Intrauterine insemination. Aboubakr Elnashar

7. FACTORS AFFECTING SUCCESS

1. Female and male age

2. Male smoking

3. Female BMI

4. Ovarian stimulation

5. Inseminating motile count (IMC)

6. Infertility status(i.e. primary/secondary infertility). (Thijssen et al, 2017)

ABOUBAKR ELNASHAR

Page 42: Intrauterine insemination. Aboubakr Elnashar

You can get this lecture from:1.My scientific page on Face book:

Aboubakr Elnashar Lectures.

https://www.facebook.com/groups/2277

44884091351/

2.Slide share web site

[email protected]

4.My clinic: Elthwara St. Mansura

ABOUBAKR ELNASHAR

Page 43: Intrauterine insemination. Aboubakr Elnashar

Endometrial scratching injury ESI

significantly improves the outcome of IUI in women

with un infertility especially when conducted 1 month

prior to IUI(Maged et al, 2016)

Piroxicam (Feldene)

10 mg/d on days 4-6 after IUI

increased PR

No effect on abortion, multiple pregnancy, (Zarei et al, 2016)

ABOUBAKR ELNASHAR

Page 44: Intrauterine insemination. Aboubakr Elnashar

B. Technique:

1. Stimulation

Natural cycle vs stimulated

Up to 5 mature follicles

Use of CC/HMG-FSH compared with CC for OS

2. Sperm preparation

Sperm preparation methods

Addition of substances in sperm preparation

ABOUBAKR ELNASHAR

Page 45: Intrauterine insemination. Aboubakr Elnashar

3. Insemination:

1. Number of inseminations

2. Time of insemination

preferably between D13 &16.

3. Number of motile sperms inseminated of more

than 5 million

Couples with <5 million motile spermatozoa inseminated should be referred directly for IVF

CPR/cycle: 5%.

Others have reported that satisfactory CPR is achieved if the motile sperms inseminated is 1 million.

ABOUBAKR ELNASHAR

Page 46: Intrauterine insemination. Aboubakr Elnashar

Cost Effectiveness

initially treatment with IUI

more cost-effective than IVF in most cases of

Unexplained

moderate male subfertility.

(Carceau et al 2002; Ombelet et al 2005)

ABOUBAKR ELNASHAR

Page 47: Intrauterine insemination. Aboubakr Elnashar

CONCLUSION

• IUI

– least expensive

– least invasive

– least stressful

– least hazardous.

• IUI alone

– useful in couples with severe sexual dysfunction

– cervical factor infertility as long as at least one fallopian tube

is patent.

ABOUBAKR ELNASHAR

Page 48: Intrauterine insemination. Aboubakr Elnashar

• ovulation predictor kit to schedule the optimum time

for the procedure.

• For patients with mild male factor, early stage

endometriosis, or unexplained infertility:

superovulation with IUI rather than natural cycle IUI (Grade 2B).

ABOUBAKR ELNASHAR

Page 49: Intrauterine insemination. Aboubakr Elnashar

You can get this lecture from:1.My scientific page on Face book:

Aboubakr Elnashar Lectures.

https://www.facebook.com/groups/2277

44884091351/

2.Slide share web site

[email protected]

4.My clinic: Elthwara St. Mansura

ABOUBAKR ELNASHAR

Page 50: Intrauterine insemination. Aboubakr Elnashar

IUI/COH

simple treatment

good LBR, especially in

younger patients and/or

those with previous parity.

More than 90% of total live births with IUI/COH is

achieved during the first two cycles.

probabilities of success can be used to individualise

treatment decisions and that there is merit in

continuing to offer IUI before resorting to IVF for

certain patients.(Geisler et al, 2017)

ABOUBAKR ELNASHAR

Page 51: Intrauterine insemination. Aboubakr Elnashar

ICSI is more cost effective than IUI when the mean total motile sperm count is <10 million

(Van Voorhis et al,2001)

Male infertility total number of motile spermatozoa (TMSC) < 20 ×106/ejaculated

(Hajder et al, 2016)

ABOUBAKR ELNASHAR