Complications may arise as a result of the insemination procedure itself or related to other interventions, such as superovulation

1. COMPLICATIONS OF ARTCOMPLICATIONS OF ART
DR NABANEETADR NABANEETA

2. Intrauterine insemination is one of theIntrauterine insemination is one of the
least invasive of all assisted conceptionleast invasive of all assisted conception
treatments. Consequently complicationstreatments. Consequently complications
are uncommon.are uncommon.

3. Complications may arise as a result of theComplications may arise as a result of the
insemination procedure itself or related toinsemination procedure itself or related to
other interventions, such asother interventions, such as
superovulationsuperovulation

4. Side effects of orally administeredSide effects of orally administered
ovulation induction agentsovulation induction agents
Hot flushesHot flushes
•NauseaNausea
•Abdominal blottingAbdominal blotting
•VomitingVomiting
•DizzinessDizziness
•DepressionDepression
•Visual disturbancesVisual disturbances
•Breast tendernessBreast tenderness
•DyspnoeaDyspnoea
•Back painBack pain
√√(10%)(10%)
√√(2%)(2%)
√√
√√
√√
√√(1.5%)(1.5%)
√√(2%)(2%)
clomipheneclomiphene
√√(18%)(18%)
√√(15%)(15%)
√√(14%)(14%)
√√(17%)(17%)
letrozoleletrozole

5. OvarianOvarian SuboptimalSuboptimal →→CancellationCancellation
responseresponse
Hyper responseHyper response
OHSSOHSS

6. OVARIANOVARIAN
HYPERSTIMULATIONHYPERSTIMULATION
SYNDROMESYNDROME
• It is the gravest complication.It is the gravest complication.
• It consists of ovarian enlargement andIt consists of ovarian enlargement and
pathologies arising from an acute fluidpathologies arising from an acute fluid
shift out of intravascular compartment in toshift out of intravascular compartment in to
the potential spaces.the potential spaces.
• Exact pathogenesis of OHSS is notExact pathogenesis of OHSS is not
known.known.

7. OHSSOHSS
* 2 types of OHSS* 2 types of OHSS
‘‘Early type” – manifest within 10Early type” – manifest within 10
days of HCG injection.days of HCG injection.
‘‘Late’ type – after 10 days of HCGLate’ type – after 10 days of HCG
injection. Caused by endogenousinjection. Caused by endogenous
HCG production by the conceptus.HCG production by the conceptus.
* Incidence is <1% in IUI cycles.* Incidence is <1% in IUI cycles.

8. RISK FACTORS FOR THERISK FACTORS FOR THE
DEVELOPMENT OF OHSSDEVELOPMENT OF OHSS
 Younger age<35 yearsYounger age<35 years
 Polycystic ovariesPolycystic ovaries
 Asthenic habitusAsthenic habitus
 Type of superovulation agents and doseType of superovulation agents and dose
 HCG luteal supplementationHCG luteal supplementation
 High serum E2 / Rapid increase in E2High serum E2 / Rapid increase in E2
>1700pgm/ml (OI)>1700pgm/ml (OI)

9. SPECTRUM OF DISORDERSSPECTRUM OF DISORDERS
IN OHSSIN OHSS
Ovarian enlargementOvarian enlargement
AscitisAscitis
HydrothoraxHydrothorax
HaemoconcentationHaemoconcentation
Electrolyte disturbancesElectrolyte disturbances
Coagulation defects & thromboembolismCoagulation defects & thromboembolism
Liver dysfunctionLiver dysfunction

10. Contd..Contd..
o Renal disordersRenal disorders
o Torsion of ovaryTorsion of ovary
o ARDSARDS
o Death is a real possibility in very severeDeath is a real possibility in very severe
cases if not managed appropriately.cases if not managed appropriately.

11. PREVENTION OF OHSSPREVENTION OF OHSS
Identification of at risk groupsIdentification of at risk groups
Modification of superovulation regimeModification of superovulation regime
Modification of gonadotropin dose .Modification of gonadotropin dose .
Change/ modify ovulation trigger.Change/ modify ovulation trigger.
Intravenous infusion of human albumin (20%)Intravenous infusion of human albumin (20%)
IUI GIFTIUI GIFT
IVFIVF

12. TREATMENT - OHSSTREATMENT - OHSS
Early recognitionEarly recognition
Patients at risk need ot be monitored 3 – 4Patients at risk need ot be monitored 3 – 4
days after inseminationdays after insemination
In mild/moderate OHSS, treatment doneIn mild/moderate OHSS, treatment done
on an outpatient basis, unless theon an outpatient basis, unless the
condition worsens.condition worsens.
Increased fluid intake.Increased fluid intake.

13. Regular hematological and biochemicalRegular hematological and biochemical
screening tests, ultrasound scans.screening tests, ultrasound scans.
Analgesics & Antiemetics.Analgesics & Antiemetics.
Reevaluatin & admission if conditionReevaluatin & admission if condition
worsens.worsens.

14. ASSESSMENTASSESSMENT
Fluid balance chartFluid balance chart
Daily measurement of abdominal girth andDaily measurement of abdominal girth and
body weight.body weight.
Full blood count, HctFull blood count, Hct
Serum albumin & total proteinSerum albumin & total protein
LFTLFT
USG : Abdomen /pelvisUSG : Abdomen /pelvis
Clotting studies.Clotting studies.

15. Treatment should be carried out by aTreatment should be carried out by a
specialist who has experience in treatingspecialist who has experience in treating
OHSS with back up cover provided byOHSS with back up cover provided by
specialists.specialists.
Restoration of normal plasma volume andRestoration of normal plasma volume and
maintenance of renal perfusion whilemaintenance of renal perfusion while
waiting for spontaneous resolution ofwaiting for spontaneous resolution of
condition.condition.

16. Antcoagulants if indicated.Antcoagulants if indicated.
Paracentesis is indicated if markedParacentesis is indicated if marked
distension of abdomen causes respiratorydistension of abdomen causes respiratory
embarrassment or failing renal function.embarrassment or failing renal function.
Surgery is seldom required unless there isSurgery is seldom required unless there is
haemorrhage / Torsion / rupture of ovarianhaemorrhage / Torsion / rupture of ovarian
cyst.cyst.

17. MULTIPLE PREGNANCYMULTIPLE PREGNANCY
Multiple pregnancy is associated with aMultiple pregnancy is associated with a
significantly higher incidence of fetal loss.significantly higher incidence of fetal loss.
Clomiphene citrate – 5%Clomiphene citrate – 5%
Gonadotropins – 25 %Gonadotropins – 25 %
Usually production of not more than threeUsually production of not more than three
follicles is the goal.follicles is the goal.

18. An optimal strategy for ovulation inductionAn optimal strategy for ovulation induction
regarding the agent and dose to be used.regarding the agent and dose to be used.
Cycle monitoring with ultrasonography andCycle monitoring with ultrasonography and
hormone assays.hormone assays.

19. OPTIONS AVAILABLE IN CASESOPTIONS AVAILABLE IN CASES
OF OVER RESPONSE TOOF OVER RESPONSE TO
SUPEROVULATIONSUPEROVULATION
Change of treatment to IVF or GIFTChange of treatment to IVF or GIFT
Aspiration of supernumerary follicles.Aspiration of supernumerary follicles.
Abandoning the treatments andAbandoning the treatments and
withholding the ovulatory injection of HCG.withholding the ovulatory injection of HCG.
Multifetal pregnancy reduction (MFPR)) inMultifetal pregnancy reduction (MFPR)) in
cases of higher order multiples.cases of higher order multiples.
- emotional or moral dilemma to couple- emotional or moral dilemma to couple

20. INFECTIONINFECTION
Incidence of pelvic infection following IUIIncidence of pelvic infection following IUI
0.01 – 0.2%0.01 – 0.2%
Possible sources of bacteria includePossible sources of bacteria include
Prepared sperm suspension.Prepared sperm suspension.
Nonsterile techniqueNonsterile technique
Contamination of the tip of catheterContamination of the tip of catheter
with vaginal organism.with vaginal organism.

21. INFECTION FROM SPERMINFECTION FROM SPERM
SUSPENSIONSUSPENSION
Semen is not sterileSemen is not sterile
Bacterial, fungal and viral organisms canBacterial, fungal and viral organisms can
be transmitted through semenbe transmitted through semen
Unscreened donor sample can be aUnscreened donor sample can be a
source of infection.source of infection.

22. Resident bacterial flora of the urethra,Resident bacterial flora of the urethra,
glans penis and hands can contaminateglans penis and hands can contaminate
the ejaculate produced by masturbation.the ejaculate produced by masturbation.
Air borne bacteria in the semen collectionAir borne bacteria in the semen collection
room.room.
Unsterile container for collection of theUnsterile container for collection of the
ejaculateejaculate

23. PRECAUTIONSPRECAUTIONS
Screening of sperm donors and quarantine ofScreening of sperm donors and quarantine of
semen.semen.
Sterile techniques during collection of sampleSterile techniques during collection of sample
Density gradient centrifugation remove virtuallyDensity gradient centrifugation remove virtually
all bacteria contained in the semen sample but itall bacteria contained in the semen sample but it
is not invariable.is not invariable.
Bacteria gets attached to motile sperms, whichBacteria gets attached to motile sperms, which
carry them into upper genital tract.carry them into upper genital tract.
Benefit of prophylactic antibiotic administration?Benefit of prophylactic antibiotic administration?

24. Women is advised to report to the unit ifWomen is advised to report to the unit if
she feels unwell.she feels unwell.
Careful evaluation with microbiologicalCareful evaluation with microbiological
techniques will reveal any infection.techniques will reveal any infection.
Prompt treatment with indicatedPrompt treatment with indicated
antibiotics.antibiotics.
Any women who is deemed at high risk ofAny women who is deemed at high risk of
pelvic infection with a significant previouspelvic infection with a significant previous
medical history, IUI is better avoidedmedical history, IUI is better avoided

25. MISCARRIAGEMISCARRIAGE
Miscarriage rate 20 – 30 %Miscarriage rate 20 – 30 %
High in assisted conception treatmentHigh in assisted conception treatment
It may be related to patient profile eg.olderIt may be related to patient profile eg.older
age / greater intensity of monitoring.age / greater intensity of monitoring.

26. ECTOPIC PREGNANCYECTOPIC PREGNANCY
Incidence in 3 – 5 %Incidence in 3 – 5 %
Normal findings at HSG and Laparoscopy do notNormal findings at HSG and Laparoscopy do not
exclude mucosal tubal pathology which canexclude mucosal tubal pathology which can
arrest the transit of embryo leading to ectopicarrest the transit of embryo leading to ectopic
pregnancy.pregnancy.
Hetertopic pregnancy is not uncommon.Hetertopic pregnancy is not uncommon.
IUI is not the first line treatment in patients withIUI is not the first line treatment in patients with
tubal pathology. But if they conceive, early USGtubal pathology. But if they conceive, early USG
evaluation from 5 weeks is indicated.evaluation from 5 weeks is indicated.

27. OVARIAN CANCER?OVARIAN CANCER?
The possibility of an association b/wThe possibility of an association b/w
ovarian stimulation and Ca ovary wasovarian stimulation and Ca ovary was
raised by Fishel & Jackson 1989.raised by Fishel & Jackson 1989.

28. HYPOTHESIS – AETIOLOGY OFHYPOTHESIS – AETIOLOGY OF
OVARIAN CANCERSOVARIAN CANCERS
Multiple ovulationMultiple ovulation →→ disruption of ovariandisruption of ovarian
epitheliumepithelium →→ Malignant transformation.Malignant transformation.
Gonadotrophin – steriod inducedGonadotrophin – steriod induced
metabolism of chemical carcinogensmetabolism of chemical carcinogens
(Xenobiotics) such as 7, 12 dimethyl(Xenobiotics) such as 7, 12 dimethyl
benz(a) anthracenebenz(a) anthracene →→ reactivereactive
intermediatesintermediates →→Destruction of follicularDestruction of follicular
cells and malignant transformationcells and malignant transformation

29. PRECAUTIONSPRECAUTIONS
Ovarian stimulation under strict monitoring.Ovarian stimulation under strict monitoring.
After 4 – 6 cycles of ovarian stimulation & IUI,After 4 – 6 cycles of ovarian stimulation & IUI,
reevaluation and IVF.reevaluation and IVF.
Further evaluation of persistent ovarianFurther evaluation of persistent ovarian
enlargement.enlargement.

30. PROCEDURE RELATEDPROCEDURE RELATED
RISKSRISKS
Allergic reactions to ingredients of IUIAllergic reactions to ingredients of IUI
preparation.preparation.
Uterine cramps, vasovagal symptomsUterine cramps, vasovagal symptoms
Difficulty in cannulationDifficulty in cannulation
Insemination with wrong sampleInsemination with wrong sample

31. CONCLUSIONCONCLUSION
IUI is relatively simple, cheap, non-invasiveIUI is relatively simple, cheap, non-invasive
method of treatment. However carefulmethod of treatment. However careful
selection of patient is important. All couplesselection of patient is important. All couples
requires in depth advice and counselingrequires in depth advice and counseling
about complication of treatment.about complication of treatment.
Reevaluation and discussion about otherReevaluation and discussion about other
treatment options such as IVF should betreatment options such as IVF should be
carried out in couples after 4 – 6 cycles.carried out in couples after 4 – 6 cycles.

32. THANK YOUTHANK YOU