Dr Anand K. Shinde (M.D)Fellow C.S.E.P.I. Centre for Assisted Reproduction Deenanath Mangeshkar Hospital, Pune – 4 Tel: 56023395, M: 98220-12166 Intera Uterine Insemination Some Practical Considerations Dr Anand K Shinde Pune
IUIWhy does it work?2. It works because Cervix is by passed3. Better quality & more number of sperms enter uterine cavity4. It is deliberately ‘timed’ near ovulation, ensuring good chance of fertilisation5. ‘Semen-washing’ process removes detrimental elements like seminal plasma, WBCS + dead sperms.
Why C.O.H. is coupled with IUI?• Timing of HCG injection predicts ovulation better, so as to schedule IUI near ovulation time.• Controlled Ovarian Hyperstimulation (C.O.H.) offers more over for fertilization & implantation, hence increases success.• C.O.H. corrects subtle endocrinopathies which block ovulation, implantation
What Success rate for IUI can be quoted?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.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.
What are contraindications to IUI• 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 age advanced• Multiple aetiologies/co-existing factors for infertility• Multiple, previous failures of IUI.
When Contraindications are ruled out, what could be indications for IUI?1. Male factors amenable to IUI2. Female factors amenable to IUI3. Indications for Donor Insemination
‘Male Factors’ helped by IUIA) Using ‘Fresh’ husband semen• Retrograde Ejaculation• Impotence or Ejaculatory Dysfunction• Hypospadias• Hypospermia (Low Volume)• Non Liquefying/highly viscous semen• ‘Subnormal’ semen parameters• Seminal Antisperm Antibody• Unexplained InfertilityB) Using ‘Frozen’ husband semen• Absent Husband (N.R.I.)• Anti cancer treatment in husband• Vasectomy
‘Female Factors’ helped by IUI• Vaginismus• Cervical Hostility• Ovulatory Dysfunction• Mild Endometriosis• Allergy to seminal plasma• Unexplained infertility
Indications for Donor Semen IUI• 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)
What are possible complications of IUI ?• Uppermost in mind but 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 Ovarian Hyperstimulation Syndrome 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.
Should we do multiple IUI in one cycle?• Ensuring presence of adequate number of motile sperms in the fallopian tube to greet the freshly ovulated oocyte is the aim of a ‘well timed’ IUI• This is possible when ovulation is triggered by injection. HCG & IUI is timed at 36 hours after it. In this method single IUI in one cycle is sufficient• Evidence shows no increase in success rate by doing ‘pre-ovulatory’ & ‘post-ovulatory’ IUI.• The problem & discussions arise because we use ultrasound to predict or demonstrate ovulation & then schedule the IUI. This has its own pitfalls.
Is post IUI antibiotic or progestational support necessary?• The couple certainly needs to be free of infection ‘prior’ to IUI• If semen shows pyospermia (W.B.C.s > 1 million/ml) or if P.C.T. or speculum inspection of cervix suggests infection it is better to clear it before IUI.• IUI per se is at low risk for infection.• Luteal phase support is individualized, it works where it is indicated only.
What other surveillance in IUI case is needed ?• In COH cycle look out for signs/symptoms of OHSS & the patient should report early• 2-5% Ectopic pregnancy :Be Alert• Multiple Gestations.
What are difficult situations in IUI couples ?• 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.