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Intrauterine Insemination
for Unexplained Infertility
Presented byPresented by
Ahmed Walid Anwar Morad, M.DAhmed Walid Anw...
OBJECTIVES
The main objective of this
presentation is to spotlight on the
role of IUI in the treatment of
unexplained infe...
Unexplained Infertility
 Definition
Unexplained infertility means that ,couple does
not conceived after 1 year of unprotected
vaginal sexual inte...
Basic investigations for diagnosis
of Unexplained infertility
 Normal basic semen analysis according to
WHO criteria (WHO...
In unexplained infertility: the cause is not
defined ,so the treatment is empirical (ASRM, 2006).
Expectant
 Encourage
 ...
 Treatment
 Dependent on:
○ Availability of resources ,
○ Patients’ age ,
○ Duration of infertility.
 The standard prot...
Suggested Protocol for Management of
Unexplained Infertility (Ray et al, 2012)
The role of IUI in treatment
of unexplained infertility
IUI
 Definition
 Rationale
 Other indications of IUI
 Steps
 Advantages
 Complications
 Indications of IUI in unexp...
Intrauterine Insemination
Definition
IUI involves the placement of
processed semen into the
uterine cavity around the tim...
 Rationale
increase the rate of
conception by
increasing the chance
that maximum number
of healthy sperms
reaches the sit...
 Indications
I. Male:
1. Ejaculatory failure: ( sever hypospadius ;retrograde
ejaculation; impotence)
2. Male factor infe...
II. Female:
1.Cervical factor infertility
2. Endometriosis
3. Ovulatory dysfunction
4. Combined non-tubal
infertility fact...
Steps
 Patient selection & counseling.
 Natural cycle IUI
 Stimulated cycle IUI (Ovarian stimulation)
 Monitoring of ...
Advantages of IUI
• Non invasive (like Pap smear).
• Bypass possible cervical mucous
hostility.
• Easy: performance and t...
IUI
Complications
Of the procedure
 Infection
 Pain
 Psychological (guilt,
anger, loss of self esteem)
Of COH
 Multipl...
IUI Indications in
Unexplained Infertility
ESHRE Capri Workshop Group (2009)
 IUI or stimulated ovary/IUI is indicated as
empiric treatment for all categories of
u...
NICE Guidance Feb, 2013
In the treatment of unexplained infertility
 The evidence does not support the use of IUI as
an ...
Effectiveness of IUI in treatment of
unexplained infertility
(Guzick et al. 1998.)
Conclusions (Cochrane, 2012 )
: In stimulated cycles PR was higher with IUI compared to timed
interc...
 NICE Guidance Feb, 2004 ; For unexplained infertility
ovarian stimulation should not be offered, even though
it is assoc...
IUI versus alternative insemination techniques
1 } Fallopian Tube Sperm Perfusion (FSP) :
 Past : FSP is superior to IUI ...
IUI Vs. IVF for unexplained infertility
 Starting treatment with IUI rather than IVF was
either cheaper or more cost-effe...
For people with:
○ unexplained infertility,
○ mild endometriosis or
○ mild male factor infertility,
who are having regular...
IUI in stimulated cycles may
be considered while
waiting for IVF or when in
women with patent tubes,
IVF is not affordable...
Favorable Predictors of IUI
Outcome
 Factors related to couples
 Factors related to therapy
A.Couple:
1.Female age ≤ 35y (Morshedi et al, 2003 )
2.Shorter duration of infertility .
3. Type of infertility (Guven et ...
A.Couple:
4. First treatment cycles (≤ 4).
 Pregnancies resulting from IUI occur during the first 3-4
treatment cycles (8...
5. Cause of infertility: (Bourn Hall clinic, 1999
;Tay et al,2007; Wang et al,2008).
Overall CPRs/cycle
 Higher PR with :...
B. Therapy: (Allahbadia and Merchant,2012).
1.Use of CC/HMG-FSH compared with CC only.
2.Follicular dynamic:
-AFC > 5 (Omb...
.3.Sperm parameters: generally
• Processed total motile sperm count ≥ 10 million, 24 h
survival > 70%, and normal sperm mo...
4.Time of insemination,
preferably between D13 &16.
5.Endometrium:
adequate thickness with trilaminar pattern
)Tomlinson e...
Measures does not affect IUI
results
1. US monitoring & HCG induction of ovulation
versus urinary LH monitoring of ovulati...
4. Type of catheter: no significant difference in PR
when using the softer Wallace catheter or the less
pliable Tomcat cat...
How to improve IUI results?
Measures to↓ complications:
1. Natural cycle IUI: ↓ PR
2. Mild ovarian stimulation : low dose ...
How to improve IUI results?
Measures to↑ PR:
1. COH: all except sever male factor ( Risks???)
(Cohlen ,2002).
2. Vaginal m...
5. Timed intercourse within 12 -18 h period: useful in IUI with low
number of motile sperm inseminated (Huang et al, 1998)...
1.Treatment of unexplained infertility is
empiric as no obvious abnormality was
detected.
2.Treatment of unexplained infer...
4.Couples should be fully informed about
the risks of IUI and COH as well as
alternative treatment options.
5. In unexplai...
7.Pre-insemination hydrotubation, US guided
IUI , cervical mucous aspiration, post-
insemination bed rest for 10 min and v...
E.mail:::ahwalid2004@yahoo.com
Intra uterine insemination for unexplained infertility
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Transcript of "Intra uterine insemination for unexplained infertility"

  1. 1. Intrauterine Insemination for Unexplained Infertility Presented byPresented by Ahmed Walid Anwar Morad, M.DAhmed Walid Anwar Morad, M.D Assistant Professor of Obstetrics and GynecologyAssistant Professor of Obstetrics and Gynecology Banha Faculty of MedicineBanha Faculty of Medicine EgyptEgypt 20132013
  2. 2. OBJECTIVES The main objective of this presentation is to spotlight on the role of IUI in the treatment of unexplained infertility
  3. 3. Unexplained Infertility
  4. 4.  Definition Unexplained infertility means that ,couple does not conceived after 1 year of unprotected vaginal sexual intercourse, with basic infertility evaluation shows no obvious abnormality (RCOG guidelines,1998; Randolph,2000; ASRM,2006).  Incidence 15% to 30% of infertile couples (ASRM,2006)
  5. 5. Basic investigations for diagnosis of Unexplained infertility  Normal basic semen analysis according to WHO criteria (WHO ,2010).  Patent fallopian tube confirmed by HSG.  Ovulation confirmed by mid-luteal serum progesterone level.
  6. 6. In unexplained infertility: the cause is not defined ,so the treatment is empirical (ASRM, 2006). Expectant  Encourage  Advice  Inform Active  IUIIUI  Oral stimulating agents (CC /Oral stimulating agents (CC / letrozole)letrozole)  CC+CC+ IUIIUI  Gonadotropin injections with orGonadotropin injections with or withoutwithout IUIIUI  IVF/ICSIIVF/ICSI  Alternatives:Alternatives:  Bromocriptine, Danazol, Tubal flushing.
  7. 7.  Treatment  Dependent on: ○ Availability of resources , ○ Patients’ age , ○ Duration of infertility.  The standard protocol is to: ○ Progress from simple to complex treatment options, ○ Balance the effectiveness against the cost and side effects. (Ray et al,2012)
  8. 8. Suggested Protocol for Management of Unexplained Infertility (Ray et al, 2012)
  9. 9. The role of IUI in treatment of unexplained infertility
  10. 10. IUI  Definition  Rationale  Other indications of IUI  Steps  Advantages  Complications  Indications of IUI in unexplained infertility  Effectiveness of IUI in unexplained infertility
  11. 11. Intrauterine Insemination Definition IUI involves the placement of processed semen into the uterine cavity around the time of ovulation (Allahbadia and Merchant,2012).
  12. 12.  Rationale increase the rate of conception by increasing the chance that maximum number of healthy sperms reaches the site of fertilization (ESHRE,2009).
  13. 13.  Indications I. Male: 1. Ejaculatory failure: ( sever hypospadius ;retrograde ejaculation; impotence) 2. Male factor infertility (mild ;moderate) 3. Sperm cryopreservation prior to treatment of husband cancer. 4. Processed semen of HIV + husband for HIV negative women (NICE, 2013)
  14. 14. II. Female: 1.Cervical factor infertility 2. Endometriosis 3. Ovulatory dysfunction 4. Combined non-tubal infertility factors III. Combined: 1. Unexplained infertility 2. Immunological infertility
  15. 15. Steps  Patient selection & counseling.  Natural cycle IUI  Stimulated cycle IUI (Ovarian stimulation)  Monitoring of treatment  Sperm preparation  Insemination
  16. 16. Advantages of IUI • Non invasive (like Pap smear). • Bypass possible cervical mucous hostility. • Easy: performance and training • Minimal: cost and risk
  17. 17. IUI Complications Of the procedure  Infection  Pain  Psychological (guilt, anger, loss of self esteem) Of COH  Multiple pregnancy  OHSS Antenatal & perinatal As pregnancies from sexual intercourse.
  18. 18. IUI Indications in Unexplained Infertility
  19. 19. ESHRE Capri Workshop Group (2009)  IUI or stimulated ovary/IUI is indicated as empiric treatment for all categories of unexplained infertility 20% of couples after initial work-up.  Couples with mild male subfertility (20–40%) 50% of those in whom conventional treatments have failed.
  20. 20. NICE Guidance Feb, 2013 In the treatment of unexplained infertility  The evidence does not support the use of IUI as an alternative to expectant management .  IUI (with or without stimulation) should not be routinely offered (exceptions e.g. when people have social, cultural or religious objections to IVF)
  21. 21. Effectiveness of IUI in treatment of unexplained infertility
  22. 22. (Guzick et al. 1998.) Conclusions (Cochrane, 2012 ) : In stimulated cycles PR was higher with IUI compared to timed intercourse Treatment % preg Expectant (No treatment ) 1.3% Natural cycle IUI 3.8% Clomiphene 5.6% Clomiphene+ IUI 8.3% Gonadotropins 7.7% Gonadotropins+ IUI 17.1% IVF/ICSIIVF/ICSI 20.7%20.7% Unexplained Infertility : PR with different treatment Options
  23. 23.  NICE Guidance Feb, 2004 ; For unexplained infertility ovarian stimulation should not be offered, even though it is associated with higher pregnancy rates than unstimulated IUI, because it carries a risk of multiple pregnancy.  Cochrane, 2012 ; risks and alternative treatment options of stimulated IUI should be discussed.  NICE Guidance Feb, 2013 ; Do not offer oral ovarian stimulation agents (such as clomifene citrate, anastrozole or letrozole) to women with unexplained infertility.
  24. 24. IUI versus alternative insemination techniques 1 } Fallopian Tube Sperm Perfusion (FSP) :  Past : FSP is superior to IUI (Trout & Kemmann,1999) .  Later: a meta-analysis reported no clear benefit (Cantineau et al, 2009) 2} No difference between IUI and Intraperitoneal insemination (IPI) (Noci et al,2007) 3} Intrauterine tuboperitoneal insemination (IUTPI) is superior to IUI &FSP (CPR/cycle 29.4% ) (Mamas, 2006) 4} IUI is superior to Intracervical insemination ICI (Besselink et al,2008).
  25. 25. IUI Vs. IVF for unexplained infertility  Starting treatment with IUI rather than IVF was either cheaper or more cost-effective than IVF in unexplained infertility (Goverde et al., 2000).  Cochrane, 2012 (Pandian et al, 2012) IVF may be more effective than IUI+SO. Due to lack of data from RCTs the effectiveness of IVF for unexplained infertility relative to expectant management, clomiphene citrate and IUI alone remains unproven.
  26. 26. For people with: ○ unexplained infertility, ○ mild endometriosis or ○ mild male factor infertility, who are having regular unprotected sexual intercourse: advise them to try to conceive for a total of 2 years before IVF will be considered . NICE Guidance Feb, 2013
  27. 27. IUI in stimulated cycles may be considered while waiting for IVF or when in women with patent tubes, IVF is not affordable (ESHRE Capri Workshop Group, 2009)
  28. 28. Favorable Predictors of IUI Outcome  Factors related to couples  Factors related to therapy
  29. 29. A.Couple: 1.Female age ≤ 35y (Morshedi et al, 2003 ) 2.Shorter duration of infertility . 3. Type of infertility (Guven et al,2008) Type of infertility Pregnancy rate Primary inf. 7.9% Secondary inf. 21.4
  30. 30. A.Couple: 4. First treatment cycles (≤ 4).  Pregnancies resulting from IUI occur during the first 3-4 treatment cycles (88-95.5%; respectively) (Morshedi et al,2003).  Aboulghar et al, 2001, suggested a maximum of 3 COH/IUI cycles for treatment of unexplained infertility  However ,others recommended up to 6 cycles (Dickey et al, 2002; Morshedi et al,2003; Ray et al, 2012).
  31. 31. 5. Cause of infertility: (Bourn Hall clinic, 1999 ;Tay et al,2007; Wang et al,2008). Overall CPRs/cycle  Higher PR with : ○ Unexplained infertility (9.2% to 22% ) ○ Ovulatory dysfunction (19.2%)  Modest PR → Cervical factor (16.4%)  Poor PR: ○ Endometriosis (11.9%) ○ Immunological infertility (10% )  ♂ factor → the best PR with ejaculatory disorders (13.3%)
  32. 32. B. Therapy: (Allahbadia and Merchant,2012). 1.Use of CC/HMG-FSH compared with CC only. 2.Follicular dynamic: -AFC > 5 (Ombelet et al, 2003) -Preovulatory follicles : 2–3 follicles≥ 16 mm with uniformly high-grade vascularity and E2 levels >500 pg/mL on the day of hCG administration. (Steures et al, 2004; Bhal et al ,2001).
  33. 33. .3.Sperm parameters: generally • Processed total motile sperm count ≥ 10 million, 24 h survival > 70%, and normal sperm morphology of >4% (according to Kruger’s criteria) predict pregnancy outcome with 94% sensitivity, 86% specificity (Guven et al, 2008;Abdelkader & Yeh ,2009).(12.3 vs 2.8%) • Initial sperm count, motility ?
  34. 34. 4.Time of insemination, preferably between D13 &16. 5.Endometrium: adequate thickness with trilaminar pattern )Tomlinson et al ,1996(
  35. 35. Measures does not affect IUI results 1. US monitoring & HCG induction of ovulation versus urinary LH monitoring of ovulation. HCG allow final follicular maturation (Kosmas et al, 2007) 2. GnRH agonist and antagonist. ↑complications (Allahbadia and Merchant,2012). 3. Double IUI versus single IUI (Polyzos et al,2009).
  36. 36. 4. Type of catheter: no significant difference in PR when using the softer Wallace catheter or the less pliable Tomcat catheter during IUI, with the standard gentle non touch technique (Smith et al ,2002). However , Merviel et al ,2010 recommended soft catheter. 5 . Luteal phase support do not appear major requirements in IUI cycles (ESHRE ,2009) 6. Sperm preparation technique (ESHRE,2009).
  37. 37. How to improve IUI results? Measures to↓ complications: 1. Natural cycle IUI: ↓ PR 2. Mild ovarian stimulation : low dose GnH 3. Cycle cancellation {> 3 follicles ≥ 16mm or; > 8 follicles ≥ 12mm} 4. Selective follicular reduction. (not routine) 4. Conversion to IVF cycle
  38. 38. How to improve IUI results? Measures to↑ PR: 1. COH: all except sever male factor ( Risks???) (Cohlen ,2002). 2. Vaginal misoprostol.???? (Brown et al,2001; Barroso et al,2001). 3. 10 -15minutes bed rest after IUI (Saleh et al,2000 ; Custers et al, 2009 ) 4. Cervical mucous aspiration before IUI (Paasch et al, 2007)
  39. 39. 5. Timed intercourse within 12 -18 h period: useful in IUI with low number of motile sperm inseminated (Huang et al, 1998). 6. Postponing IUI until the observation of follicle rupture by TV sonography ( PR;25% vs 8.8%) (Kucuk ,2008). 7. US guidance in IUI (Ramón et al,2009; Oztekin et al,2013) 8. Pre-insemination hydrotubation (Edelstam et al, 2008; Aboulghar et al, 2010 ; Morad & Abdelhamid , 2012)
  40. 40. 1.Treatment of unexplained infertility is empiric as no obvious abnormality was detected. 2.Treatment of unexplained infertility is very much dependent on availability of resources and patients’ age and duration of infertility . 3.OH with IUI is a simple ,cost-effective, least invasive first-line treatment for Unexplained infertility.
  41. 41. 4.Couples should be fully informed about the risks of IUI and COH as well as alternative treatment options. 5. In unexplained infertility OH with IUI may be considered while waiting for IVF or when IVF is not affordable. 6. The pregnancy rates of FSP & Standard IUI are similar.
  42. 42. 7.Pre-insemination hydrotubation, US guided IUI , cervical mucous aspiration, post- insemination bed rest for 10 min and vaginal misopristol may improve IUI outcome . 8. In unexplained infertility, up to 6 cycles of IUI should be considered before shifting to IVF.
  43. 43. E.mail:::ahwalid2004@yahoo.com
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