Panel IUI by DR SHASHWAT JANI ( Optimizing Success in Intrauterine Insemination )

OPTIMIZING
SUCCESS IN IUI
PANEL DISCUSSION

 What are Male and Female factors for IUI.?
 Indications for donor IUI?
2e- mail: drshashwatjani@gmail.com

 Retrograde Ejaculation
 Impotence or Ejaculatory Dysfunction
 Hypospadias
 Hypospermia (Low Volume)
 Non Liquefying / highly viscous semen
 ‘Subnormal’ semen parameters
 Seminal Antisperm Antibody
 Unexplained Infertility.

 Vaginismus
 Cervical Hostility
 Ovulatory Dysfunction
 Mild Endometriosis
 Allergy to seminal plasma
 Unexplained infertility

 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)

 Spontaneous.
 Clomiphene
 Clomiphene + Gonadotrophins
 Gonadotrophins.
What are the Standard Protocols…???

 Gonadotropins only
 Gonadotropins with CC
 Gonadotropins with GnRH analogs
 Gonadotrophins with GnRH antagonists

Standard protocol
 Most commonly used
 Started from day 3,4,5
 Daily or alternate days
 75 to 150 IU / day till hCG

 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

 ↑ Consumption
Vs. CC / Letrozole + gonadotropins
 ↑ OHSS
 ↑ Multiple pregnancy
 ↑ ↑ Cost
 Injections only

 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

 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

 Adv. : Effective
 Can prevent LH surge
 Choice of protocols
 Dis. adv. : Additional medication
↑ Gonadotrophin dose
↑ Cycle cost
↑ Length of treatment

 Occupy pituitary GnRH receptors
 Direct & immediate effect
 No flare response
 Immediate reversal
 Constant supply is must

 Adv.:
- ? ↓ Gonadotropin requirement
- ? ↓ Duration of treatment
- Can use GnRH agonist for LH surge
- CC/ Letroze can be used
 Disadv.:
- Cost

 What are the Standard Sperm
Preparation Techniques…?
Effect of Sperm count in success
of IUI.

 Remove : Seminal plasma and debris
Pus cells, RBCs
Prostaglandins
Antigens
 Separate best motile and morphologically
normal sperm.
 Achieve Capacitation

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

 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 ?

 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.

 Timing of hCG administration :
With CC Cycle : Follicle size 20 -24 mm
With HMG Cycle : Follicle size 18 mm .
ET at least 8 mm.

 Ideally 36 -38 after HCG administration
OR
After Confirmation of Ovulation.

 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… !!! ;-)

 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 ?

 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.

Complications of IUI :
Contraindications 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.

 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.

 Difficult situations in IUI Couples :
 Total No. of IUI Cycles :

 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.

 Female age < 35 years :
Maximum 6 cycles.
 Female age > 35 years :
Maximum 3 cycles then go for IVF…!!!???

 What success rate for IUI can be quoted ?
 Limitations of IUI ?
 Why IUI fails.?

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. 33e- mail: drshashwatjani@gmail.com

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.

• 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.

 Hospital and lab distance.
 Proper maintenance of standard of Lab.
 Sperm requirement in millions
 Fertilization can not be assured
 Quality of embryo unknown…

e- mail: drshashwatjani@gmail.com 37

Panel IUI by DR SHASHWAT JANI ( Optimizing Success in Intrauterine Insemination )

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Panel IUI by DR SHASHWAT JANI ( Optimizing Success in Intrauterine Insemination )