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net
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Traditional:
(widely used 0.2-0.5 ml washed sperm intraut).
Modified ( Fallopian tube sperm perfusion):-
Twice as effective (Trout and Kemmenn 1999).
4ml of prepared semen over 4min (1ml each min).
Insemination performed before ovulation (Oocyte
flushed out of the tube).
Intrauterine Inseminations (IUI)
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As a technique:
Direct intrauterine insemination (neat semen)
- Disadvantage:
- PG cramps
- I nfection.
Split ejaculate
The advances in IVF, ET. reviving IUI.
History of IUI
Abondoned
(Stone et al,
1986)
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Advances in:-
Progress in semen processing and sperm isolation methods.


Improved ovarian stimulation protocols (developed primarily to
meet IVF requirements) side effects.

IUI progress is due to advances in
IVF, ET.
Reviving the interest in IUI
+
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Advantages of I UI
Bypass (Vaginal acidity + cervical mucus hostility)
Deposition of a well prepared sperms as close as
possible to the oocytes (Short distance)
Non invasive (like pap smear).
Inexpensive.
Antenatal & perinatal complications (like
pregnancies from normal S I)
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Disadvantages
1. Multiple pregnancy (>IVF) number of
follicles will grow or rupture can not
precisely controlled.
2. Infection Iatrogenic infertility.
3. Psychological (guilt- anger- loss of self
esteem)
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Selection + counseling
Protocol (spontaneous or stimulated cycle)
Folliculometry&Endometrial thickness.
Timing of insemination.
Semen preparation.
Procedure:

I UI Steps

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Complete work up of infertility:
(Semenogram- midluteal progestrone - HSG + laparoscopy)
I ndications.
Adequate counseling
Confidence of husband.
Religious
Cost
Failure & success
Complications.
Selection and counselling
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Success of I UI
The review of literature over the past 15 years




Take home baby
wide range of variation
0-26% pregnancy / cycle in different indications
MIFIC (22%).


Controversy No evidence- based infertility data.
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Factors affecting success of
I UI
Couple:
(age,duration of infertility,cause of infertility,BMI).
Therapies:
Semen processing technique.
Protocol of COH.
Timing of insemination.
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Timed intercourse versus IUI
Probability of conception
Natural cycles (IUI )
COH cycles (IUI )
( Cochrane database 2000)



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Spontaneous cycle protocol
Cervical factor.
Sexual dysfunction.
-D 10-11 monitor every 2 days.
-Follicle 18-20 mm hcg 10,000 u.
-Insemination 36 h after hcg.
-Pregnancy test (hcg in serum 2w after
insemination).
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Ovarian Stimulation Protocol
Rationale for use COH



Protocols commonly used

-Number of oocytes available
-Steroid production ( chance of implantation )




cc (2x50mg) day 2 to day 6 of menstruation
+ FSH or hmg (75 IU) daily from day 5 + HCG.
FSH only (75 IU) from day 3 + HCG.
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Ov. Stim. Protocol con..
TVS monitoring of follicular growth and endometrial
development
-Baseline TVS (day 2 -3 of Menst.)
-Serial TVS (day 7-8 of stimulation)
-Follicle 18-20 mm hcg 10,000 u.
-Insemination 36 h after hcg.
-Pregnancy test (hcg in serum 2w after insemination).

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Rationale:
viable sperms should be present at the time of ovulation.
Detection of ovulation
serum or urinary LH
TVS (leading follicle > 18mm) HCG 10.000 IU
I nsemination:
one versus two (24 h & 48 h) from HCG
or TVS after 36 h :
1- Ovulate IUI
2- Not Ovulate IUI at once
IUI 24H later

Timing of insemination
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Rationale:-
Concentration of progressively motile and
morphologically normal spermatozoa into
a small volume of culture fluid.
Elimination seminal plasma (PG-
lymphokines- cytokines - antigens - infectious
matter).
Reduce the number of free oxygen radicals.
Semen processing
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Prior to insemination.
Cuscos speculum.
Catheter (types)
During insemination:
Utero cervical angle
Catheter insertion.
I nsemination (catheter withdrawal)
After insemination
Rest ?!
Luteal phase support

Procedure of I UI
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Where IUI is done?
Ideally in a clinic with IVF facilities
(all services under one floor)
-OHSS
-IVF choice.
-Freezing extra embryos.
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Where IUI is done?
I UI in the office setting
Benefits:
1. OB/Gyn extend their fertility care beyond
the basic workup to provision of first-line
therapies.
2. Maintaining the existing parent-OB/Gyn
relationship for a longer period without
referral.
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Pre-Requisites for office IUI
1. Organization the practice to be extended in
the week ends or holidays.
2. TVS probe Ovulation prediction kits.
3. Office semen processing or RSP service
(Remote Semen preparation).
4. Familiarity about the optimal time for
referral the case to an infertility specialist.
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RSP
Prepare the semen for IUI (seven days/
week)
Assurance of quality control, semen
analysis before and after IUI preparation.
Patient/ partner are able to safely transport
processed semen & IUI kits.
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Recent advances: SIFT
(Sperm Intrafallopian transfer)
Speically designed catheters (Jansen-
Anderson Catheter Sets)

The processed sperm can be injected into
the tubes laparoscopically OR guided by
ultrasound without anaesthesia or
surgrey.
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Conclusion
While many gynecologists offer IUI office procedure,
many of them are not specialized enough to provide
a comprehensive service. This means that:
1. Patients need to run from gynecologist to ultrasound
scan center to the lab.
2. Fragmented care because of poor coordination.
SO
An ideal clinic is that which offers all the services under
one roof.
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T HANK YOU
Prof. DR. MOHAMMAD EMAM
Prof. OB& GYN, Mansoura Faculty of Medicine
Member of Mansoura Integrated Fertility Center (MIFC)
Telefax 0020502319922 & 0020502312299
Email. mae335@hotmail.com