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net
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Advantages of IUI
Bipass (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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Success of IUI
The review of literature over the past 15 years





Take home baby
wide range of variation
0-26% pregnancy / cycle in different indications
Mansoura integrated Fertility Center ( MIFC)
(18%).


Controversy No evidence- based infertility data.
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Ejaculatory failure (Hypospadius- Vaginismus- Impotence-
retrograde ej.)
Cervical factor (mucus hostility-poor mucus)
spont cycle protocol.
Male subfertility (Mild, moderate)
Immunological (Male sperm a.bs- female antisperm a.b)
Unexplained.
Husband is away from wife for long time (work
abroad)
Indications for IUI-H
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Endometriosis (mild).
Ovulatory (?! Induction + timed sexual I).
Combined non tubal infertility factors.
HIV negative women with processed semen of
HIV +ve husband.
Cancer-husband: cryopreservation of semen
prior to chemo, radiotherapy or orchidectomy.
Indications Cont...
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Factors affecting
success of IUI
Couple:
(age,duration of infertility,cause of infertility.)

Therapies:
Semen processing technique.
Protocol of COH.

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Timed intercourse versus IUI
Probability of conception
Natural cycles (IUI )
COH cycles (IUI )
( cochrane database 2000)
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Questions remain to be answered
(Evidence - based fertility ???)
Which type of couples with
male subfertility benefit
most from COH + I UI

?
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Is I UI and /or COH cost effective for male
subfertility compared with I VF? And for how
many cycles?
What is the threshold level for numbers of
motile spermatozoa after sperm preparation
beyond which treatment outcome is no longer
improved? Or what is the minimum number of
motile sperms below which IUI is no longer
effective
? ? ?
Cont..
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What is the Answer??
Male subfertility
Pre processing: (mild or moderate), not severe.

Count Motility Morphology
Million/ml (G1+G2%) (N%)
Mild 15-20 40-50 30-40
Moderate 10-15 20-40 10-30
Severe <10 <20 <10
Post processing: inseminated motile sperms
G1 > 1 million/ml.
WHO
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Pre-requisities
Optimizing the
office.
Optimizing the
knowledge.
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Pre-requisities cont.
Optimizing the office for IUI:

1. Organization of the practice to be extended
in the week ends or holidays.
2. Availability of TVS probe.
3. Utilize remote semen preperation ( RSP )
4. Utilize remote folliculometry service.
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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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Pre-requisities cont.
Optimizing The Knowledge For IUI:
The gynecologist should be aware of:
1. Indications
Be sure that:
Women not have a concomitant condition that
would prevent successful insemination.

2. Semen processing.

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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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Techniques Semen processing

Centrifugation (two step washing)(Wiltbank et al,1985).
Swim-up (Sher et al,1984).
Glass wool filteration (Jeyendran et al,1986).
Per coll density gradient (Smith,1995).
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Pre-requisities cont.
Optimizing The Knowledge For IUI:

The gynecologist should be aware of:
3. IUI workup.
4. Different protocols of superovulation.
5. Prevention of complication of superovulation.
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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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Pre-requisities cont.
Optimizing the Knowledge for IUI:

The gynecologist should be aware of:
6. The optimal time for
referral the case to an
infertility centers (The
biological clock ticks with
every failed attempt for
conception)
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Awareness of The Time of
Referral To Infertility Centers
1. Age > 35 Y.
2. Failed 3 IUI.
3. Severe male subfertility.
4. Number of mature follicles >4 (not give HCG).
5. Number of follicles (>12 mm) >8 (not give HCG).
6. Extensive endometriosis.
7. Need for cryopreservation of semen.
8. Non optimized office.
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IUI is relatively simple, cheap, effective
and is non-invasive method.
Careful selection of patient is important.

Young women with patent tubes, no
ovulatory disorder, no moderate or
severe endometriosis and no severe
degree of male factor.
Conclusions
Most who will benefit are:
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Conclusion cont
For practicing IUI as an office
procedure pre-requisities
regarding optimization of the
office and knowledge of
gynecologists should be
present
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Although IUI can be performed in an
optimized office, but centers with IVF
facilities offer the best setting, as there is
a chance of:
Selective follicular reduction.
Conversion to IVF.
Freezing any extra embryos.
Conclusions cont
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OB& GYN, Mansoura Faculty of Medcine
Mansoura Integrated Fertility Center (MIFC)
EGYPT
Telfax 0020502319922 & 0020502312299
Email. mae335@hotmail.com