Intrauterine insemination (IUI) is a fertility treatment involving the placement of washed sperm into the uterine cavity and is indicated for various infertility causes, excluding tubal disease. Success rates vary based on factors such as female age and sperm quality, with combined treatments showing higher pregnancy rates than IUI alone. Proper timing of IUI and effective sperm preparation methods are crucial for maximizing the chances of conception.

1. Intrauterine
insemination

2. oInfertility, defined as inability to conceive after 6 months of unprotected
intercourse
oIntra uterine isemination is the process of placing washed spermatozoa
transcervically into the uterine cavity
oCompared to other ART , IUI is simple and less expemsive
oSafe and relatively easy procedure

3. Indications
oUnexplained infertility
oMild male factor
oligo/ astheno/ teratozoospermia
oEndometriosis
oImmunological factors
cervical , seminal
oEjaculatory failure
neurological , anatomical , psychogenic

4. oWith sperm count < 5 million , or patients with more than 1 abnormal sperm
parameter, ICSI is more acceptable
oTubal disease is not an indication for IUI
o In patients with ejaculatory failure (severe hypospadias ,retrograde ejaculation
and impotence) , IUI success rates depends on sperm quality
oIn patients with progressive sperm motility of 20-30 % prognosis is good .

5. oCervical factor infertility – PCT ( post coital test ) , for assessing the sperm
motility in a sample of post coital cervical mucous
oPCOS – induction of ovulation with IUI - pregnancy dates found to be 11-20%
oThes are tried in women with PCOS who failed to conceive despite successful OI

6. Factors influencing IUI outcome
oAge of female partner – pregnancy rates were
24 % with age < 35 years
18 % 35-37 years
15.1% 38-40 years
1.8% > 40 years
oDuration of infertility – decrease in pregnancy rates if duration of infertility is
high
oAetiology – lower pregnancy rates with endometriosis
oNumber of IUI cycles – most pregnancy occurred between 3-6 IUI cyclesm

7. o No evidence that double insemination give rise to higher live birth rates
o33 % pregnancy rates for combined IUI and OI
o18% for IUI alone

8. Ovulation induction for IUI
◦ Empiric ovarian stimulation with clomiphene citrate or exogenous gonadotropins
is commonly combined with IUI in the treatment of couples with male factor
infertility
◦ cycle fecundability (probability of pregnancy per cycle) is higher after combined
treatment than after IUI or ovarian stimulation alone in couples with unexplained
infertility.

9. ◦ When male factor infertility is the diagnosis, and ovulatory function is normal,
treatment with IUI alone is reasonable and appropriate.
◦ When IUI in spontaneous cycles or indicated clomiphene-induced cycles fails
(approximately 3–4 cycles) or when the female partner is over age 35, exogenous
gonadotropin stimulation may be expected to improve the likelihood for success.

10. Sperm Preparation
The most common methods include conventional washing, the “swim-up”
procedure, and density gradient centrifugation.
Both the conventional washing and swim-up methods allow sperms to remain in
contact with dead or defective sperms and leukocytes, which produce high levels of
reactive oxygen species that may cause oxidative damage to sperms membranes
and motility.
Density gradient centrifugation, glass wool filtration are more effective to remove
dead cells

11. Washing
 The simplest method of washing sperms involves diluting the liquefied semen
sample in buffered medium in a sterile tube (1:1–1:3, depending on volume),
followed by low-speed centrifugation (200–300g for approximately 10 minutes) and
removal of the supernatant.
 After two or more cycles, the final pellet is resuspended in a small volume
(approximately 0.5 mL) of medium for insemination. Sperm washing yields the
greatest numbers of sperms, but the final specimen also contains dead and
abnormal sperms and other cellular debris

12. SWIM UP
The final pellet is gently overlaid with 0.5–1.0 mL of fresh medium and incubated
at 37°C for 30–60 minutes, allowing the most motile sperms to swim up into the
supernatant.
The method generates a cleaner specimen, devoid of dead sperms and other
cellular debris, but also yields significantly lower numbers of sperms

13. DENSITY GRADIENT CENTRIFUGATION
The typical methodology for density gradient centrifugation involves overlaying the
liquefied ejaculate on a column of higher-density media that are layered to create a
gradient of increasing density from the top to the bottom of the column, followed
by low-speed centrifugation for 15–30 minutes.
 The most highly motile sperms traverse the gradient more rapidly and can be
recovered from the soft pellet at the bottom.
The method also appears to select a population of sperms with normal morphology

14. Timing and Technique
IUI should be timed to coincide with the time of spontaneous or induced ovulation.
 Normal sperms can survive in the female reproductive tract and retain the ability
to fertilize an egg for at least 3 days, but an oocyte can be successfully fertilized for
only approximately 12–24 hours after it is released.
In normal fertile couples, the probability of conception rises progressively over an
interval of 5–6 days and peaks when intercourse occurs on the day before or day of
ovulation

15.  Cryopreservation damages sperms, The timing of IUI in the treatment of male
factor infertility is therefore far more critical for success than the timing of natural
intercourse in infertile couples, regardless whether infertile partner sperms or
frozen donor sperms are used.
In natural and clomiphene-stimulated cycles, the most practical and reliable
method for timing IUI involves urinary LH monitoring beginning approximately 3
days before expected ovulation and insemination on the day following detection of
the LH surge.

16.  When ovulation is triggered by injection of exogenous hCG in natural or stimulated
cycles, IUI generally is best performed approximately 34–40 hours later.
Immediately before performing IUI, removal of any excess mucus that might clog
the catheter tip is recommended. The tip of the insemination catheter is then
simply inserted into the cervical os and advanced slowly into the uterine cavity.
The insemination specimen (approximately 0.5 mL) should be introduced slowly
over 10–30 seconds.

17. Donor Sperms
Require extensive screening of prospective sperm donors before acceptance.
Semen quality, to include an evaluation of sperm viability and motility after a trial
freeze and thaw, excludes approximately 75% of all candidates.
Personal health history and physical examination, family medical history, genetic
screening for cystic fibrosis and other carrier states (depending on ethnicity),
Screening for sexually transmitted infections (syphilis, gonorrhea, Chlamydia,
cytomegalovirus, hepatitis B and C, HIV types I and II, and human T-lymphocytic
virus [HTLV] types I and II

18. sperm specimens must be quarantined and cannot be released for use unless they
have remained sequestered for at least the 180 days preceding the most recent
negative test for HIV
As when using infertile partner sperms, the likelihood of success with therapeutic
donor insemination increases with the number of motile sperms in the specimen
and is greatest when the count exceeds 20 million.
 Most sperm banks guarantee a minimum number of motile sperms in each
specimen.