Treatment Choices for Slip Disc at Gokuldas Hospital
PPT IUI B.Inggris.pptx
1. TIPS AND TRICKS TO PREVENT COMPLICATIONS
IN INTRAUTERINE INSEMINATION
Presenter:
RESIDENCY PROGRAM OF OBSTETRIC AND GYNECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
DR. MOHAMMAD HOESIN HOSPITAL PALEMBANG
2023
3. INDICATION
3.
Husband or partner’s
semen
• Male subfertility
• Cervical factor
• Ejaculatory failure
• Idiopathic/unexplained
infertility
• Immunological
infertility
• Endometriosis
Donor insemination
• Gross male infertility
or subfertility
• Familial or genetic
disease
Dickey, R., Brinsden, P., & Pyrzak, R. (Eds.). (2009). Manual of Intrauterine Insemination and Ovulation Induction. Cambridge: Cambridge
University Press. doi:10.1017/CBO9780511642159
4. COMPLICATIONS
4.
Before
IUI
Anxiety
Side effects of
drugs for
Ovulation
induction
During
IUI
Pain
Vasovagal attack
Spotting
Infection
Cramp
ACOG. Treating Infertility. The American College of Obstetricians and Gynecologists. 2019.
Dickey, R., Brinsden, P., & Pyrzak, R. (Eds.). (2009). Manual of Intrauterine Insemination and Ovulation Induction. Cambridge: Cambridge University Press.
doi:10.1017/CBO9780511642159
7. MANAGEMENT AND PREVENTION
7.
Complete
assessment
Male
Semen quality
Treat all disorders involving the
reproductive tract that can be
corrected
Female
Proper workup to get an
accurate diagnosis of the cause
of subfertility or infertility and
right treatments
8. MANAGEMENT AND PREVENTION
8.
• Diazepam 10 mg
Anxiety
• Gonadotropins the initial dose should be as low as
possible and monitored with frequent ultrasound and
serum hormone levels.
• CC and TMX discontinued immediately
Side effects of
drugs for
Ovulation
induction
• Semen is not sterile added antibiotics to the culture
media.
• Sperm wash followed by density gradient centrifugation.
• Procedure and technique clean and sterile
Infection
9. MANAGEMENT AND PREVENTION
9.
• Before use taenaculum Application of lidocaine jelly
• General anesthesia or cervical block If necessary
Pain
• Psychological support
• Cool damp cloth to the fore head
• Maintaining airway
Vasovagal
attack
• Laparoscopy diagnostic as well as therapeutic purpose
• Laparotomy may be required
• Preserve the normal IUP while treating the EP
• May requiring blood transfusion.
Heterotopic
pregnancy
10. MANAGEMENT AND PREVENTION
10.
• Outcomes depend on patient and cycle specific factors.
• For male TMC > 5 million sperm, post-wash sperm
count > 1 million.
Failure of
the treatment
• Antibiotic prophylaxis not recommended in any of
these procedures unless there is a concomitant risk factor.
PID
11. MANAGEMENT AND PREVENTION
11.
• Complete assessment
Allergic
reactions
• Complete assessment IUI did not provoke
antisperm antibody formation in women who had
not previously been sensitized
Antisperm
antibodies
• Chromosome analysis
Genetic
abnormalities
12. MANAGEMENT AND PREVENTION
12.
• IUI alone may increase the proportion of male
births, and that this increase may be negated by the
use of CC (Clomiphene Citrate).
Sex ratio
• A quality assurance program for the andrology
laboratory should include record keeping, routine
equipment calibration and maintenance, and
regularly scheduled proficiency testing of
laboratory technologists.
Laboratory
or clerical
error
13. REFERENCE
1. ACOG. Treating Infertility. The American College of Obstetricians and Gynecologists. 2019.
2. Allahbadia GN. Intrauterine Insemination: Fundamentals Revisited. J Obstet Gynaecol India [Internet]. 2017 Dec 1;67(6):385–92.
3. Dickey, R., Brinsden, P., & Pyrzak, R. (Eds.). (2009). Manual of Intrauterine Insemination and Ovulation Induction. Cambridge: Cambridge
University Press. doi:10.1017/CBO9780511642159
4. Matorras R, Rubio K, Iglesias M, Vara I, Expósito A. Risk of pelvic inflammatory disease after intrauterine insemination: a systematic
review. Reprod Biomed Online. 2018 Feb 1;36(2):164–71.
5. Starosta A, Gordon CE, Hornstein MD. Predictive factors for intrauterine insemination outcomes: a review. Fertil Res Pract. 2020 Dec;6(1).
6. Waheed H, Masroor I, Afzal S, Alam MS, Khan F, Kumari U, et al. Quadruplet heterotopic pregnancy; ectopic managed successfully with
laparotomy with subsequent viable intrauterine pregnancy: A case report. Radiol case reports. 2022 May 1;17(5):1528–31.
13
The term “artificial insemination” (AI) covers a range of techniques for insemination: it may be intravaginal, intracervical, intrafallopian, intraperitoneal or intrauterine. AI has been used for many years for a number of different indications.
Intrauterine insemination (IUI) is a fertility treatment that involves directly inserting sperm into a woman's womb. IUI is an effective, non-invasive, relatively simple and cost-effective method.
Ejaculatory failure is the classical indication, since the male partner is unable to ejaculate into the vagina, while cervical mucus hostility is a logical indication for IUI, as it bypasses the mucus in the cervical canal. The most common indications for IUI are the less severe forms of male-factor infertility and idiopathic or unexplained infertility. Other indications, for which conclusive evidence of effectiveness is lacking, are immunological causes of infertility and endometriosis.
The main indications for donor insemination are (1) gross male infertility or subfertility (azoospermia or severe oligoasthenoteratozoospermia), for couples who cannot afford IVF or reject IVF for other reasons, and (2) familial or genetic disease, such as Huntington’s disease, hemophilia and severe Rhesus incompatibility.
Before
IUI procedures are mildly uncomfortable. Patients may exhibit more than usual anxiety.
Side effects of drugs for Ovulation induction. There continues to be discussion in the literature about whether or not IUI should be complemented by OI, either with the oral medications clomiphene citrate (CC) or tamoxifen (TMX), or with the injectable gonadotropins. the intentional use of gonado \tropins at higher doses and for longer periods to induce multiple follicular development, brings up the two most serious complications of gonadotropin stimulation – high-order multiple births and hyperstimulation. Side effects of CC are hot flashes and visual symptoms. Visual symptoms may be blurring or spots and flashes (scintillating scotoma).
During
Pain rarely results in the need to abandon the procedure entirely.
A vasovagal attack, consisting of a transient vascular and neurogenic reaction marked by pallor, nausea, sweating and a rapid fall in arterial blood pressure, may occasionally occur during insemination procedures and result in brief loss of consciousness.
Sometimes the process of placing the catheter in the uterus causes a small amount of vaginal bleeding. This doesn't usually have an effect on the chance of pregnancy.
There's a slight risk of developing an infection as a result of the procedure.
Cramping during the IUI usually happens as the catheter is being passed through the cervix, and while the sperm is being injected. This cramp is usually pretty short-lived.
Heterotopic pregnancy (HP) occurs due to the simultaneous presence of both the intrauterine pregnancy (IUP) and ectopic pregnancy (EP), either live or demised.
Failure of the treatment could be said to be the most frequent, since pregnancy rates per cycle are reported at anywhere between 5% and 25%.
In some cases of IUI, the introduction of the catheter through the cervical canal and the release of washed sperm could prompt the ascension and spread of cervical microorganisms into the uterus and the tubes. It is well known that ascension of microorganisms is the main mechanism of PID genesis.
Before proceeding to artificial insemination, couples should undergo a complete assessment. This includes a thorough medical history, clinical examination and appropriate investigations for any possible causes of a couple’s infertility. A complete assesment is needed to prevent the complication.
In male, it focuse to improve the semen quality. Treat all disorders involving the reproductive tract that can be corrected. A wide range of disorders involving the male reproductive tract may cause deterioration of seminal parameters. Any correctable pathology needs to be treated prior to the use of assisted reproductive techniques
In female, need proper workup to get an accurate diagnosis of the cause of subfertility or infertility and right treatments
Anxiety
Patients who exhibit more than usual anxiety may be given a mild sedative such as diazepam 10 mg.
Side effects of drugs for Ovulation induction
When using gonadotropins for OI, the initial dose should be as low as possible until the ovarian response can be evaluated, in order to avoid multiple pregnancies. . Gonadotropin stimulation should not be started unless the patient can be monitored with frequent US and serum hormone levels. CC and TMX should be discontinued immediately if visual symptoms occur, but can be restarted at a lower dose in the next cycle.
Infection
Infection
Semen is not sterile; therefore, antibiotics are routinely added to the culture media used for sperm preparation and insemination. Sperm preparation methods that include sperm migration or centrifugation through density gradient media remove most, but by no means all, bacteria contained in semen.
Genital herpes virus, hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV) are all known to have been transmitted through use of donor sperm. There is no unanimous agreement that sperm itself can act as a vector for HIV and there is a close correlation between the circulatory viral load and the viral load in seminal fluid. Sperm wash followed by density gradient centrifugation has been shown to result in sperm specimens that contain no detectable viral load.
insemination should performed in an ordinary gynecologic examination room with clean. The patient is draped as for a vaginal examination. The physician or nurse performing the procedure is attired in the laboratory coat or other clothing ordinarily worn when performing a gynecologic examination. Latex gloves are worn and universal infectious disease precautions are followed.
Pain
When a tenaculum is necessary to straighten the cervix, or when cervical stenosis requires dilation, application of lidocaine jelly should be considered.
In rare instances, general anesthesia or cervical block may be necessary.
Vasovagal attack
No treatment other than psychological support and a cool damp cloth to the fore head is usually necessary. Maintaining the airway, especially if a patient has a history of epilepsy, diagnosis must be considered and particular attention must be given
Heterotopic pregnancy
Laparoscopy serves as a diagnostic as well as therapeutic purpose. Depending on the situation of the patient, conversion to laparotomy may be required.
The main caution that should be taken into account is to preserve the normal IUP while treating the EP. HP is often an asymptomatic condition. However, it can mimic EP or abortion. Vaginal bleeding and abdominal pain, signs of peritonitis and adnexal mass are the commonly found features in symptomatic cases. Hypovolemic shock is more commonly found in HP compared to EP requiring blood transfusion.
Failure of the treatment
IUI is a frequently utilized and effective treatment for infertility, but outcomes depend on patient and cycle specific factors.
Most data support IUI for men with a TMC > 5 million sperm, with some studies showing a threshold effect at a TMC of 10 million. Post-wash sperm count > 1 million is recommended, with increasing pregnancy rates as count increases but with a plateau in pregnancy rates after post-wash sperm count reaches 4 million.
PID
Prophylactic antibiotic therapy is not recommended, unless there is a pre-existing risk factor. The occurrence of PID after IUI is a rare complication, and no reliable data on its frequency have been published; therefore, it is difficult to give exact information to patients, and to make decisions about prophylactic antibiotic therapy
Allergic reactions
Although allergic reactions from antibiotics in IUI specimens have been reporteded, no patients have been report to be allergic to this low concentration of gentamicin, which used in the sperm processing methods. But complete assessment to know about the allergic is still needed.
Antisperm antibodies
Antisperm antibodies (ASA) form when the barrier is compromised, commonly through trauma, testicular biopsy, vasectomy or infection. ASA can be detected in semen, serum and cervical mucus, usually using the immunobead test, which is available at most specialized andrology laboratories. ASA interfere with sperm transport in the female reproductive tract, and with the egg–sperm interaction. They are found in 3–12% of men presenting for infertility evaluation.
IUI did not provoke antisperm antibody formation in women who had not previously been sensitized, but increased the antibody titer in women who already had serum antisperm antibodies. Complete assessment is needed to know the women had previously been sensitized or not.
Genetic abnormalities
Moderate oligospermia and severe oligospermia are associated with abnormal karyotypes in approximately 1% and 10% of males respectively. These abnormalities include Y-chromosome abnormalities, balanced translocations, Klinefelter’s syndrome (XXY) and XY/XXY mosaics. In cases of severe oligospermia, conception as a result of IUI is unlikely. Even though the possibility of a child being conceived by IUI with sperm from a male with severe oligospermia is low, it is advisable to obtain a chromosome analysis before proceeding.
Sex ratio
Whether IUI and/or OI alter the sex ratio at birth has been a recurrent matter of conjecture. It suggest that IUI alone may increase the proportion of male births, and that this increase may be negated by the use of CC.
