intrauterine insemination - physicians training module
Post on 07-May-2015
Embed Size (px)
DESCRIPTIONThis slide deck is prepared keeping in view the need of understanding the procedure of IUI (Intrauterine Insemination). Being a professional working in the field of infertility management, it was very difficult for me to find such material on IUI in which all the relevant information is gathered on one yet to the point and concise platform. So I developed this presentation to help you guys. My role was to gather the relevant data in one simple yet elaborate presentation. Nothing in this presentation is personally written by me, so I have mentioned the references very clearly. I hope the readers will find it very useful. Intrauterine insemination (IUI) is a procedure that involves placing sperm inside a womans uterus to facilitate fertilization. This fertility treatment does not involve the manipulation of a womans eggs, and therefore is not considered an assisted reproductive technology (ART) procedure.
- 1.Physicians Training Module Dr. Sarwat Jabeen MBBS, MBA Health Management & Pharmaceutical MarketingProduct Manager Fertility
2. Intrauterine insemination (IUI) is a form of treatment where sperm are inserted into the uterine cavity around the time of ovulation. IUI can be carried out in a natural cycle, without the use of drugs, or the 5 ovaries may be stimulated with oral antiestrogens or gonadotrophins.1. NICE Guidelines - 2012 3. The procedure allows one to bypass the cervix to deposit sperm closer to tubal ostium, thereby facilitating a larger number of motile sperms to reach the fertilization site in the ampulla of fallopian tube. In addition, the sperm separation procedure would remove WBC, dead and moribund sperms generating free oxygen radicals which reduce the functional capacity of intact sperms. Components in the media also induce gentle capacitation of sperm which is necessary to make them functionally ready for fertilization. Controlled ovarian stimulation is often used in conjunction with IUI treatment which also enhances the chance of pregnancy by inducing multiple ovulation. 4. Where drugs are used to stimulate a cycle, in the case of oral antiestrogens a woman will take a course of tablets for 5 days. With gonadotrophins (E.g. rFSH-Puregon) the woman usually receives a course of daily fertility injections for 7 to 10 days. However, the exact duration of stimulation will depend on which day of the cycle it is started. In both circumstances the treatment should be monitored by ultrasound scan to assess the ovarian response.1. NICE Guidelines - 2012 5. When one to three follicles are seen to have developed to a suitable size, usually with one dominate follicle, then an injection of hCG is given which triggers ovulation. Insemination of prepared sperm will be undertaken 24 to 36 hours later. However, in order to reduce the risk of multiple pregnancies if more than three follicles have developed or two or more mature follicles are seen then insemination may not be undertaken.1. NICE Guidelines - 2012 6. Unexplained infertility Mild endometriosis Mild male factor infertility Disability (physical or psychological) preventing vaginal sexual intercourse Conditions that require specific consideration in relation to methods of conception (such as after sperm washing in a couple where the male is HIV positive) Fertility preservation As part of donor insemination IUI in stimulated cycles may be considered while waiting for IVF, or when in women with patent tubes IVF is not affordable.1. NICE Guidelines 2012. 2. Human Reproduction Update, Vol.15, No.3 pp. 265277, 2009. IUI The ESHRE Capri Workshop Group 7. IUI is contraindicated in women with: Cervical atresia Cervicitis Endometritis Bilateral tubal obstruction In most cases of amenorrhea or severe oligospermia1. Human Reproduction Update, Vol.15, No.3 pp. 265277, 2009. IUI The ESHRE Capri Workshop Group 8. Female age 35 nmol/L/Male partner: Two semen analysis revealing at least 10 million recovered motile sperm / whole sample 9. Patient with any of the following diagnosis could be considered for IUI treatment: Unexplained infertility Male factor Immunological factors Cervical factors 10. Proper indication Satisfactory semen analysis Patent, healthy fallopian tubes Need to increase FSH threshold in early follicular phase with either oral ovulation inducing agent and / or injections of exogenous gonadotropin preparations (E.g. Puregon) Identify or preempt the spontaneous LH surge 11. Detailed clinical history of both partners Counseling for IUI procedure Detail explanation of the technique, risk, complications and expected outcome. Examination of the Female Patient Physical examination and local Transvaginal Sonography Day-21 serum progesterone Tubal assessment by laparoscopy / hysterosalpingogram If the patient has got irregular menstruation baseline hormones should be done 12. Poor results have been described when IUI was performed in natural cycles for unexplained and cervical factor. The rationale behind the use of ovarian hyperstimulation in artificial insemination is the increase of the number of oocytes available for fertilization and to correct subtle unpredictable ovulatory dysfunction. Drugs for OI in IUI: Oral Anti-estrogens (Clomiphene Citrate Ovafin) 50 100 mg for five days Aromatase Inhibitors (Letrozole) 2.5 7.5 mg for five daysInjectables hMG 75 150 mg / day from day 3 7 of cycle FSH uFSH or rFSH (E.g. Puregon) 75 150 mg / day from day 3 7 of cycle hCG (E.g. Pregnyl) 5000 10,000 IU for follicle puncture and to time insemination 1. Human Reproduction 2008. Intrauterine insemination (IUI) as a first-line treatment in developing countries and methodological aspects that might influence IUI success. 2. Ovarian stimulation protocols (anti-oestrogens, gonadotrophins with and without GnRH agonists/antagonists) for intrauterine insemination (IUI) in women with subfertility (Review). Copyright 2011 The Cochrane Collaboration. 13. The drugs for OI in IUI A Comparison: Intra-uterine insemination combined with OH has been proven effective for couples with unexplained and mild male factor subfertility. Compared with IVF, IUI with OH is less invasive and more cost-effective . Antiestrogens Vs. Gonadotropins In the 2007 Cochrane review of seven trials, the results demonstrated that in an IUI program, ovarian stimulation with gonadotrophins increases pregnancy rates per couple significantly, compared to anti-oestrogens, without effecting adverse outcomes.Antiestrogens Vs. Aromatase Inhibitors In the 2007 Cochrane review of five studies, None of the trials solely or in combination provided convincing evidence of a significant difference.1. Ovarian stimulation protocols (anti-oestrogens, gonadotrophins with and without GnRH agonists/antagonists) for intrauterine insemination (IUI) in women with subfertility (Review). Copyright 2011 The Cochrane Collaboration. 14. WHO Reference ValuesReference LimitSemen volume (ml)1.5Sperm concentration (106/ml)15Total sperm number (106/ejaculate)39Progressive motility (PR, %)32Total motility (PR +NP, %)40Vitality (live sperms, %)= / > 58Sperm morphology (NF, %)=/>4pH*= / > 7.2Leucocyte* (106/ml)