This document provides an overview of intrauterine insemination (IUI). Some key points include: IUI is a first-line, non-invasive fertility treatment that involves placing processed sperm directly into the uterus. Success rates range from 6-20% depending on the stimulation protocol used. Factors like age, infertility duration and etiology, and semen quality impact success rates. Strict monitoring is important to minimize risks of ovarian hyperstimulation syndrome while maximizing pregnancy chances. Proper sperm processing techniques and timing of insemination relative to ovulation are also important considerations for IUI.

1. Intrauterine Insemination
UPDATE
DR. SHARDA JAIN
DR. JYOTI AGARWAL
DR. JYOTI BHASKAR

2. Over 350 ppts are available on
slideshare.net ***for use of public/Doctors
www.slideshare.net / Lifecarecentre

3. OVERVIEW
• Aim
• Definition
• Prerequisites
• Individualisation of patient.
• Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
• Newer trends
• Sucess Rates in IUI with COH
• PROGNOTIC FACTORS to increase
Pregnancy Rates..& discussion

4. Singleton
live birth
at term
;
Multiple
Pregnan
cy
10- 15%
Cycle
Cancellati
on
2-8%
Bcz of
Risk of
OHSS
OHSS
Severe
0%
Moderate
3-8%
.
Our Aim
Minimize Risks

5. A cost Effective , non invasive first line therapy &
inexpensive method of treatment that involves the
deposition o a processed semen sample in the
upper uterine cavity
* IUI is easily done in simple setups.
IUI

6. PRE REQUISITES FOR IUI
• Atleast one patent functional tube
• Evidence of ovulation
• Adequate sperm count
• Responsive endometrium

7. INDIVIDUALISING
TREATMENT PROTOCOL
is the key
STRICT CANCELLATION POLICY in
Gonadotrophic stimulation protocol
to limit MULTI- FOLLICULAR development
may help to avoid OHSS as OHSS is not
acceptable.

8. NEWER TRENDS
Though the technique of I.U.I. has remained same.
Several advances in
• TYPE OF STIMULATION protocols,
• wider USE OF GONADOTROPHINS,
• SPERM PREPARATION techniques tailored to
every specimen
• Meticulous ULTRASOUND monitoring
has led to improve success rates with I.U.I.

9. PREGNANCY RATE IN A.R.T.
million dollar information
Method Pregnancy Rate (%)
Intercourse (Timed) 4
IUI 6
CC 6
CC+IUI 8
FSH / HMG 7.7
CC / FSH /IUI 9-12
FSH/ HMG/IUI 17 – 20 %
In vitro fertilization 20 to maximum 40% [self cycle]
50 to 60 % donor cycle

10. CONTROLLED OVARIAN
HYPERSTIMULATION..Is the key
COH, particularly with CC,LETROZOLE, LOW
DOSE GONADOTROPHINS,with IUI offers
significant benefit in terms of PREGNANCY
OUTCOMES compared with NATURAL cycle or
TIMED INTERCOURSE,while reducing
associated COH complications such as
MULTIPLE PREGNANCIES & OHSS

11. IMPOTANT PROGNOSTIC
INDICATORS OF SUCCESS with I.U.I.
• >35 YRS of AGE OF FEMALE PATIENT
• DURATION OF INFERTILITY
• STIMULATION PROTOCOL[review in slideshare.net 2017]
• INFERTILITY ETIOLOGY
• NUMBER OF IUI CYCLES
• TIMING OF INSMINATION
• TECHNIQUE OF IUI
• NUMBER OF PREOVULATORY FOLLICLES ON THE DAY OF
HCG
• SEMEN QUALITY & FEW OBSERVATION ON MALE FACTOR

12. ADVANCED MATERNAL AGE
≥ 35 YEARS
is the most important factor

13. AGE OF WOMAN is The
Biggest Factor
Substantial decline in
fertility occurs at 35 .
Decrease in ovarian reserve in
Indian women is observed 6 to
7 years earlier

14. As Age Advances, Number Of Eggs
Decline
Faddy et al., 1992

15. Likelihood of Getting Pregnant
by Age
The likelihood of infertility dramatically increases for women after

16. Miscarriages Increase with
Age
The likelihood of miscarrying increases with age.

17. • Ovarian response declines rapidly after 35 years of age
• HFEA data for AID – 2008 confirms women age factor
Women Age is most important
& has a direct correlation
with probability of success of IUI
Our experience - no success in IUI after 40 year
Age of lady No of IUI Live birth rate
40-42 yrs 492 23/492 = 4.7%
43 – 44 172 2/172 = 1.2%
>44 46 0/46 = 0%

18. INDICATION of IUI (Aetiology)

19. CPR in IUI—8 to 20 %
depending upon indication & Protocols
• Anovulatory infertility
• Cervical infertility
• Azoospermia [AID]
• unexplained infertility
• Immunological abnormalities
• Mild degrees of male factor infertility
• Non-consummation of marriage due to –
ED/vaginismus

20. Grading of Success & Indication
for IUI
• Anovulatory infertility
• Cervicalfactor infertility
• Azoospermia
• Unexplained Infertility Age over 35
•Endometriosis
•Immunological infertility
•Male factor – poor TMSC
Best Outcome
Good
Outcome
Poor Outcome

21. Good Result
: - Cervical Factor I
: - Anovulatory I
: - Unexplained I
: - Donor IUI
Poor Results :- severe male infertility
tubal factor/
pelvic adhesions
severe endometriosis

22. Direct referral to IVF/ICSI is to be
done earlier than LATE
• ADVANCED MATERNAL AGE
• SEVERE MALE FACTOR INFERTILITY
• TUBAL PATHOLOGY
• SEVERE ENDOMETRIOSIS
As IUI IS OF NO BENEFIT
IN THESE CASES

23. Who are
GOOD or BAD RESPONDERS

24. Good Responders :- young
:- Good Crop of
Preovulatory follicles
:- Good ET (> 7 mm)
:- Good PWS count
Poor Responders
:- Older self / partner,
:- ↑ duration infertility (> 5 yrs)
:- Poor Ovarian Responce
:- Poor Endometrial Thickness
:- Poor Sperm Quality

25. Semen & Male Factors

26. AGE < 45 yrs
>10 million prewash count
Over 5 million Post Wash Count
Normal morphology – 5 % (Krugers)
DNA fragmentation -< 15 %
Sperm survival (24 hours) - ↑ 70 %
Male-good prognosis factors

27. Male Factor & SEMEN PARAMETERS –
which impact IUI Outcome
• Oligospermia [ 10 million ]
• SEMEN PROCESSING TIME
• Pre wash TOTAL MOTILE SPERM COUNT
• Post Wash Sperm MOTILITY AFTER PROCESSING.
• SPERM MORFOLOGY
• Critical IUI INSEMINATION TIME [from sample production to
INSEMINATION
• 24-H SPERM SURVIVAL

29. Pre wash MOTILE SPERM COUNT
An average total motile sperm count of 10x106
may
be a
USEFUL THRESHOLD VALUE
for decisions about treating a couple with IUI or
IVF.
When initial values are lower, IUI has little
chance of success
Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine
insemination and in vitro fertilization. Van Voorhis BJ, et al. Fertil Steril 2001 Apr;75(4):661-8
Comparison of the sperm quality necessary for successful intrauterine insemination with World
Health Organization threshold values for normal sperm. Dickey RP, et al. Fertil Steril 1999
Apr;71(4):684-9

30. The post wash total motile sperm
count ≥ 5 X 106
is critical
Total motile sperm count – TMS count
> 5 mil associated with good outcome while
TMS < 1 mil has very poor outcome
Van weert et al. performance of the postwash total motile sperm count as a
predictor of pregnancy at the time of intrauterine insemination : a meta – analysis .
Fertil steril . 2004 ; 82:612

31. Patients with more than 60% normal
sperm morphology (NSM) had higher
pregnancy rate than those with less
than 60% NSM (24.3% vs. 7.7%,
P=0.0052).
IMPACT OF
SPERM MORPHOLOGY
Intrauterine insemination: pregnancy rate and its associated factors in a university
hospital in Iran Zahra Rezaie, et al. Middle East Fertility Society Journal,Vol. 11, No. 1,
2006, pp.59-63

32. Sperm Morphology
Now krugers criteria is followed
Sperm morpholgy – best outcome are seen with
4-14 % normal sperm morphology with strict
kruger’s criteria
Predictive value of normal sperm morphology in intrauterine
insemination (IUI): a structured literature reviw Hum Reprod, 7 (2001), pp 495 - 500

33. WHO GIVES LOT EMPHASIS ON KRUGERS CRITERIA---BUT NO LAB
IN INDIA GIVES REPORT USING KRUGERS CRITERIA

34. Effects of high sperm DNA
fragmentations are
•Infertility
•Recurrent pregnancy loss
•Poor outcomes in IUI and IVF
Men with poor semen parameters
are more likely to have high DNA
fragmentations

35. The term DNA fragmentation refers to
Damaged sperm DNA that can not be repaired

36. Sperm DNA fragmentation
index-DFI >30% correlates with poor
pregnancy rate & high
rate of miscarriage

37. 24 – hours SPERM SURVIVAL -
HIGHLY PREDICTIVE OF IUI SUCCESS
24 - hours
Survival Rate….>70 %
Advanced semen analysis: a simple screening test to predict intrauterine
insemination success. Branigan EF, et al. Fertil Steril 1999 Mar;71(3):547-51
Easy test

38. IUI-H V/S IUI-D
12th
ESHRE report on IUI
Accumulated results from 1,69,469 cycles from across 26 countries
Procedure No % increase
since 2006
Delivery Rates
IUI – H 144509 + 1.5 % 9.1%
IU – D 24960 - 4.3 % 13.8%
V. Goosens et al, human Reprod. Sept 2012

39. SEMEN EJACULATION,
PROCESSING & INSEMINATION TIME
Very very important
most of the gynaecologist donor know and follow
IDEAL TIME..Is less than 90 mts DELAYING
SEMEN PROCESSING FROM 30 min Upto one
hour.
• Delaying I.U.I. insemination FROM 90 min upto
2 hour after collection -
compromises the PREGNANCY OUTCOME in
COH - I.U.I. CYCLES

40. SPERM-PREPARATION
TECHNIQUES- IUI RESULTS
•ABNORMAL SEMEN ANALYSES.
–Density gradient is superior to the swim-up technique in
improving Pregnancy rates.
• NORMAL SEMEN ANALYSES.
–When only nuclear maturity rate is taken into account, the
swim-up technique seems to be sufficient for selecting
spermatozoa.
Sperm-preparation techniques for men with normal and abnormal semen analysis.- A comparison.
Erel CT, et al. J Reprod Med 2000 Nov;45(11):917-22

41. Strict criteria no longer valid . In IUI we can
use either technique
Normal sample: Pellet swim up
Low VOLUME : pool samples, simple WASH
Low COUNT : pool samples, simple WASH
Low MOTILITY : simple WASH or Gradient
Highly ABNORMALS :Gradient (80-90%)
High DEBRIS : Gradient (80-90%)
FLAKES : Allow to settle, remove
flakes, Gradient (80-90 %)
SUM UP of SeMen SaMPle for IUI

42. Counselling Tips in
MALE FACTOR INFERTILITY
• Prewash Sperm COUNT has been independently associated with
PR in MALE FACTOR INFERTILITY.
• P REWASH Sperm Count should be >10 MILLION for IUI..if less
I.V.F. Is desirable.
• 24 – SPERM SURVIVAL OF > 70 %---good prognosis
• NORMAL MORPHOLOGY before sperm separation > 4 -15 %
• RAPID PROGRESSIVE MOTILITY >25.% After sperm washing
• CURVILINEAR VELOCITY after sperm separation >102.65 um/s
Independently predict pregnancy outcome in patients with
MALE FACTOR infertility.

43. STIMULATION PROTOCOLS
already reviewed in

44. SUMMARY
• Typical PR 4 / 8 / 12 / 20 depending on protocol used
in TI/CC/CC+HMG /Low dose Gonadotrophins
• Gonadotrophins yield BEST RESULTS
• Antagonist in IUI protocol .. PROMISE BETTER results
• Recommendation is to keep IUI simple
Individualized Ovarian Stimulation Protocol

45. S
• CC – is known to have negative effect on ET –
EV -effectiveness ?
Delay hcg trigger –in CC cycles
• GT cycle has better ET
• Scratching of Endometrium—Is now used routinely
• ↑Endo Vascularity
(Aspirin/ Viagra / Sidnafil) ---many drugs but NO clear answer … .so we do not
use
. GCSF..offers promise
Poor Endometrial Thickness
<7 mm has negative impact on PR

46. TWO PPTS ON THIN ENDOMETRIUM.
ALREADY ON SLIDESHARE.NET
• Thin Endometrium Granulocyte Colony Stimulating
Factor (GCSF)- What, How and When to use in IUI
• Thin Endometrium & Infertility

47. • Ultrasound monitoring – Allows follicle & endometrial
evaluation in IUI,
• Dose of gonadotrophin & EV can be adjusted in same & if
necessary in subsequent cycles
• Assessment for the risk of OHSS
• Time HCG Trigger
Ultrasound Monitoring
Do it your self
endometrial appearance/thickness is more important than follicle size
for hCG administration

48. AIM is to have 2-3 Follicles of >16 mm size
in Gonadotrophin cycle in IUI
• Higher risk of OHSS development
If there are more than 4 follicles larger than 16 mm or more than 8
follicles larger than 12 mm
• If need arises Serum.E2 should be measured along with
ULTRASOUND to rule out OHSS
• If >1500 pg/ml…councel patient for OHSS &Consider cancelling
the cycle.

49. NUMBER OF FOLLICLES &
Pregnancy Rate
No of follicles Pregnancy Rate
1 5.7%
2 13.6%
3 16.3%
4 OR MORE Risk of OHSS & multiple
pregnancies – cancel cycle
Huttenen et al (1999)

50. Trigger time change with COH
GT – 17-18 mm
CC -24 -25 mm
Doppler - Perifollicular perfusion 50 – 70 %
HCG - should use HCG 5000 iu to trigger
S/C HCG - (BMI)…5 or 10 K
Agonist trigger –not recommended as it causes
luteolysis,which leads to poor pregnancy rate
OVULATION TRIGGER

51. SINGLE v/s DOUBLE IUI
Single IUI IS GOOD Enough - if there is No Male
Factor
Double IUI recommended in Male factor
1st
18- 24 hrs
2nd
36 – 40 hrs [post-ovul]

52. • Single insemination : 36 – 38 hrs post HCG
• Double insemination :
- 1st
:24 hrs. post HCG
- 2nd
: 48 hrs. Post HCG
IF + LH surge - Give HCG trigger immediately
- IUI 24 hrs
Time of Inseminations

53. But we all feel IUI should be done post
ovulatory or go for two IUI
Pre VS Post Ovulation IUI : No Consensus
Kucuk (2008) – found better (25% compared to 8%) pregnancy rates when IUI was postponed till follicle
rupture was observed
Mohd. E Ghanm et al (2010) – found better pregnancy rates (11.7% vs 6.7%) when IUI done post
ovulation

54. • Labeling.. of specimen
• Regular IC as long Abstinance
not good (<3 V/S > 10 days)
• Semen collection in House
• Semen preparation IN house
.. SPERM preparation … One size does not fit all
• High quality Consumables & media

55. in
infertility
centre
IN-HOUSE
IUI
Should be
done

56. From Sperm deposition to – sperm
Ovum interaction :
4 steps take place in cervix ,uterus & FT
1. Capacitation
2. Acrosome Reaction
3. Hyperactivation
4. Sperm- Oocyte binding

57. I.U.I. Takes away step I & II

58. in
infertility
centre
IN-HOUSE
IUI
Should be
done
Reminding
you
again

59. EASY IUI
GIVES BEST RESULTS

60. ss
• Partially Full Bladder
• Lithotomy position
• Cx mucus aspiration
• Target time - 90 minutes
• Type of Catheter—soft v/s rigid
• Insemination volume—0.3 -0.5 ml/insemination
• Load – when ready
TECHNIQUE OF I.U.I.
Success lies in looking into
details of techniques

61. ss
• No free space
• Atromatic entry..
• No last word still as to hold cervix or not
• Inject sample beyond intrnal os but 1.5 cm below from
fundus
• Rest 10 mints/post procedure rest –not necessary.
• For difficult cases—do it under ULTRASOUND guidance
• Emergency trey
TECHNIQUE OF I.U.I.
Success lies in looking into
details of techniques

62. • Progesterone is the best
• Vaginal progesterone is 6 times more potent
than oral medication
LUTEAL SUPPORT

63. Luteal support & Antagonist Protocol
• Agonist trigger 0.1 mg decapepty1 if more tan
10 follicles.
• Micronized progesterone 200 mg bid in case
of hCG trigger
• Micronized progesterone 400 mg bid in case
of agonist trigger.
• hCG 1500 IU on day of IUI & after 4 days to
rescue luteal phase in case of agonist without
aggravating the risk of OHSS

64. Number of IUI cycles
• Most pregnancies occur in the first 3 attempts
• IUI treatment is not usually recommended for more
than a maximum of 4-6 cycles
• If the reason for infertility is anovulation, then also
NO MORE THAN 6 cyces.
Plosker SM, et al. Predicting and optimizing success in an intra-uterine
insemination programme. Hum Reprod. 1994 Nov; 9(11): 2014-21

65. Thumb Rule
• COS+IUI is effective
it works in FIRST 3 to 4 cycles.
• Don’t repeat IUI again and again
IVFafter three failed IUI cycles is advised.
3 IUI = 1 IVF
Don’t waste time!

66. ALL DOCTORS PRACTICING INFERTILITY/DOING I.U.I.in
INDIA NEED TO HAVE
INFERTILITY REGISTRATION
IVF..... REGISTRATION is already the practice

67. The effect of patient and semen characteristics on live birth
rates following intrauterine insemination : A Retrospective
study HENDIN B. N.et al. Journal of assisted reproduction
and genetics ; 2000, vol. 17, no
5, pp. 245-252
• Advanced female age
• Poor postwash sperm motility count<5 million
• History of corrective pelvic surgery
Poor postwash sperm motility in combination with
either of these other two risk factors resulted in no
successful pregnancies
RECAP
RISK FACTORS FOR POOR OUTCOME WITH IUI

68. DOCUMENTATION/REPUTATION OF
TEAM
• Integrity of Team
• Right documentation
• Analysis of Result what works
& what does not work

69. To DECIDE -WHEN TO MOVE FROM IUI TO
IV For Adoption?
• Each centre should define its policy when to switch
for IVF, which takes into account
• AGE OF WOMEN
• Selection of Indication & protocol
• Pregnancy rates achieved by IUI clinic

70. TAKE HOME MESSAGES
• IUI should be offered to younger age couples with shorter
duration of infertility
• Semen parameters should be assessed before putting a
couple for IUI
• There is no point in repeating IUI beyond 3 - 4 well planned
attempts
• Mild induction protocols should be preferred
• Patient education on what to expect before starting
treatment helps set correct expectations

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