Intrauterine Insemination (IUI) is the therapeutic introduction of sperms in the uterine cavity

Function of the Cervix

-Cervical Secretions-Physiological Filter-Capacitation & Stores

Carrying out the Cervical Function in the Laboratory

- getting rid of debris, abnormal sperms, seminal plasma- picking up good motile sperms- invitro capacitation

Indications

-Cervical Infertility

-Male Infertility

Oligoasthenozoospermia

Azoospermia

Retrograde Ejaculation

Husband living abroad for long stretches of time

-Donor Insemination

-Unexplained Infertility

-Immunological Infertility

-Mild Endometriosis

-Allergy to Seminal Plasma

Contraindications

-Unhealthy Tubes

-Acute Genital Infection

-Hyperstimulated Ovaries

-Medical/Psychological/Social

Sample Collection

-Masturbation

-Split Ejaculate

-Viscous Sample

-Pooled Ejaculates

Rotunda - The Center For Human Reproduction

-Swim-up using Medicult Flushing Medium

-Density Gradient Separation using Medicult SupraSperm

Buffer Systems & pH

Most Media Utilize The Physiological Bicarbonate/CO2 buffer system to maintain a physiological pH of around 7.4 in the medium.

-Preparation Methods Without Centrifugation Will Be Preferred

-Reactive Oxidative Stress Induced By Reactive Oxygen Species (ROS) Such As Hydrogen Peroxide & Super Oxide Anion

-ROS Affect The Unsaturated Fatty Acids On The Plasma Membrane Of The Spermatozoon

Techniques of IUI

The Volume of the Inseminate

The Type of Insemination

Type of Catheter used for Insemination

The Type of Insemination

Bolus Technique

Pulsatile Intrauterine Insemination

Slow Release Intrauterine Insemination

Why Slow Release?

SRIUI More Physiological

SRIUI may induce local PGs which may improve sperm transport

BoIUI may have an adverse immunological impact

BoI may cause polyspermia

Type of Catheter used for Insemination

“Atraumatic Embryo Transfer is Essential for Successful Implantation”-Leeton J, Trounson A, Jessup D, Wood C. The technique for human embryo transfer. Fertil Steril 1982;38:156-161.

Wood C, McMaster R, Rennie G, Trounson A, Leeton J. Factors influencing pregnancy rates following IVF-ET. Fertil Steril 1985;43:245-247.

-Englert Y, Puissant F, Canus M. Clinical study on embryo transfer after human IVF. J In Vitro Fertil Embryo Transfer 1986;3:243-246.

-Diedrich K, van der Ven H, Al-Hasani S, Krebs D. Establishment of pregnancy related to embryo transfer techniques after IVF. Hum Reprod 1989; 4 (Suppl) :111-114.

Timing of IUI

After insemination, cryopreserved semen retains its fertilizing capacity no longer than 24 hours. Thus, it is very important to time your inseminations well.

Two Inseminations before & after ovulation resulted in a higher PR when compared with a single insemination.

Silverberg et al. Fertility & Sterility 1992;57:357-361

Duration of Treatment

OI with gonadotropins & IUI compared with IVF & no therapy: a prospective nonrandomized, cohort study and meta-analysis

Peterson et al. Fertil-Steril 1994;62(3)535-44.

Cost-benefit analysis comparing hMG & IUI, IVF, & no therapy in infertility patients may favor a course of four cycles of hMG and IUI as the first line of therapy. Using meta-analysis & theoretical assumptions, the PR for one cycle of hMG & IUI is inferior to IVF, GIFT, or ZIFT; two cycles are comparable to IVF or ZIFT & inferior to GIFT; 3 cycles are superior to IVF or ZIFT and comparable to GIFT; and four cycles are theoretically superior to all techniques.

Reasons for the high PRs with Superovulation & IUI

-Superovulation corrects subtle ovulatory disorders- Superovulation increases the number of preovulatory follicles-Increase in ovarian size may bring the ovary in close proximity to the fimbria- Superovulation may affect tubal vascularity to enhance ovum pickup mechanisms-Swim up techniques enhance fertilizing capacity of sperms-IUI increases the number of sperms reaching the Ampullo-Isthmic Junction

Predicting & optimizing success in an IUI program

Fluker SM et al. Hum-Reprod 1994;9(11):2014-2021

IUI is not beneficial to women >40 years old, and has the best chance of success within three cycles. Multiple follicle recruitment using hMG based protocols and midcycle hCG are necessary to achieve an acceptable PR.

Results

June 97-May 98

Indications No. of Pts. No. of Ins. Pregnancies Abortions

Unexplained 48 110 12(25%) 5Tubal Factor 10 27 2(20%) 1Anovulation 29 54 4(13.8%) 1Endometriosis 1 2 - -Immunological 2 3 - -Male Factor 36 78 4(11.1%) 2Multiple Factors 10 41 1(10%) -Donors 22 119 6(27.3%) -Total 158 434 29(18.35%) 9

Does IUI offer an advantage to cervical cap insemination in a donor insemination program?

Williams DB et al. Fertil-Steril 1995;63(2):295-98

Value of sperm morphology assessed by strict criteria for prediction of the outcome of IUI

Toner JP et al. Andrologia 1995;27(3):143-48

A comparision of IUI in superovulated cycles to intercourse in couples where the male is receiving steroids for the treatment of autoimmune infertility

Robinson JN et al. Fertil-Steril 1995;63(6):1260-1266

Complications

Pregnancy after IUI with Sperm retrieved from the rectum

Gleicher N et al. Fertil-Steril 1994:67(3);554-555

A randomized prospective comparision between IUI & FSP for the treatment of Infertility

Karande VC et al. Fertil-Steril 1995;64(3):638-40.

The overall PRs per cycle (10.8% versus 10.2%) were similar for IUI and FSP respectively. The PRs were also similar when compared for ovulation induction with CC (6.8% versus 9.1%) and gonadotropins (13.2% versus 11.8%).

Fallopian Tube Sperm Perfusion

“Until we have evaluated the procedure of FSP using the principles of Evidence Based Reproductive Medicine13, we should not designate FSP as one of the milestones of reproductive medicine as has been attempted by certain groups.”

Desai SK, Allahbadia GN. Middle East Fertility Society Journal 4(2);173-174:1999.

Gamete Intrauterine Transfer

Lens S et al. Baillieres-Clin-Obstet-Gynaecol 1992;6(2):339-49