This document outlines the protocol for intrauterine insemination (IUI). It describes the indications for IUI including male factor infertility and various types of female infertility. It details the workup that should be done prior to IUI including semen analysis and ultrasound exams. The steps of the IUI process are explained, including ovarian stimulation when needed, follicle monitoring, sperm preparation techniques, timing of insemination, and the insemination procedure. It recommends offering 4 to 6 cycles of IUI.

1. INTRAUTERINE INSEMINATION
Protocol
Aboubakr Elnashar
Benha university hospital, Egypt

2. INDICATIONS
A. Male:
I. Ejaculatory failure:
anatomical (hypospadias), neurological (spinal cord
injury), retrograde ejaculation (multiple sclerosis)
II. Male subfertility:
hypospermia, oligospermia, asthenozoospermia,
teratozospermia (OAT syndrome).
Severe male infertility (Count<10 million/ml, normal
morphology <10% or motility <20) is not candidate
for IUI but ICSI.
IVF with ICSI is more cost effective than IUI when
the mean total motile sperm count is <10 million
(Van Voorhis et al, 2001)
ABOUBAKR ELNASHAR

3. B. Female:
I. Cervical factor:
cervical mucous hostility, poor cervical mucous
II. Endometriosis:
mild & moderate
III. Ovulatory dysfunction
IV. Combined non-tubal infertility factors
ABOUBAKR ELNASHAR

4. C. Both:
I. Immunological:
male antisperm antibodies, female antisperm
antibodies (cervical, serum)
II. Unexplained infertility:
Superovulation with IUI is the first choice treatment
for:
Mild male factor infertility,
Unexplained infertility or
Minimal to mild endometriosis
ABOUBAKR ELNASHAR

5. WORKUP PRIOR TO IUI
For male:
Semen analysis
For female:
Hysterosalpingogram
Baseline ultrasound:
To exclude ovarian cysts or endometrial polyps
D2 or 3 FSH & LH:
Elevated LH & FSH may predict poor follicular
response.
Raised LH/FSH: PCOS: excessive response.
ABOUBAKR ELNASHAR

6. STEPS
I. Ovarian stimulation
In unexplained infertility & male factor infertility:
CC 100 mg from D2 to 6 & FSH 75 IU daily from
D5
FSH 75 IU daily from D3.
When the leading follicle is >18 mm: 5000 –1000 IU
of HCG to achieve final follicular maturation &
rupture.
ABOUBAKR ELNASHAR

7. II. Monitoring of follicular growth & endometrial
development
Baseline U/S:
Serial U/S: From D8 of stimulation
ABOUBAKR ELNASHAR

8. III. Timing of insemination:
HCG (5000-10000 IU) or rLH (Ovatrell)
when the leading follicle >18mm: ovulation should
be expected to occur 34 to 36 h after the injection.
HCG should be withheld if
1. Number of mature follicles > 4
2. Number of follicles > 12 mm > 8
ABOUBAKR ELNASHAR

9. Single insemination:
34 to 36 H after the hCG injection.
Double insemination
If low sperm count or male factor infertility.
1st: 12 H from the hCG administration
2nd: 34 H from the hCG administration.
Coitus
On the day of hCG administration.
ABOUBAKR ELNASHAR

10. IV. Sperm preparation:
Swim-up technique:
simple and the cheap
Density gradient centrifugation (DGC):
Most of studies show no difference in the IUI
outcomes with the use of either technique, although
a borderline benefit of DGC over swim-up technique
was shown by a meta-analysis by Duran et al.
ABOUBAKR ELNASHAR

11. Collection of semen:
1. By masturbation into a sterile container after 3-5
days of sexual abstinence.
2. The container should be warm {minimize the risk
of cold shock}
3. Addition of culture media to the pots before
semen collection {improve motility} if there has been
previous marked viscosity
4. In cases of impaired liquefaction, increased
viscosity & inferior semen quality: obtain split
ejaculate (the first 3 ejaculatory emissions are
collected separately).
{In 90%: the highest sperm concentration, better motility, lower viscosity
& lower PG concentration are present in the first split fraction. In 10%:
semen quality is superior in the second fraction}.
ABOUBAKR ELNASHAR

12. V. Insemination
Precautions:
1. Aseptic technique to avoid infection
2. Gentle technique to avoid trauma of the
endometrium {may lead to cramping & bleeding
which may adversely affect the survival of
spermatozoa}
The use of tenaculum during IUI may not affect the
pregnancy outcome.
(Park, 2010)
ABOUBAKR ELNASHAR

13. Technique:
1. Lithotomy position
2. The cervix is exposed with bivalve speculum &
rinsed with saline
3. The catheter is firmly connected to the cone of
1cc tuberculin syringe, the plunger is withdrawn
slightly, & the sperm suspension is then aspirated
from the test tube into the catheter without any air
bubbles.
If catheter passage through the cervix is difficult:
grasp the cervix with tenaculum to straighten the
utero-cervical angle by gentle traction
ABOUBAKR ELNASHAR

14. 4. The catheter tip is advanced close to the fundus
& inseminate is gently expelled.
Leave the catheter in place for short time & then
withdraw it slowly to avoid suction effect & prevent
reflux
5. Supine position for 15 min.
ABOUBAKR ELNASHAR

15. NUMBER OF CYCLES
IUI with or without COH should be offered for 4 to 6
cycles.
{Little benefit if any beyond the sixth cycle}.
ABOUBAKR ELNASHAR

16. ABOUBAKR ELNASHAR