Traditional: (widely used 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)

As a technique : Direct intrauterine insemination (neat semen) - Disadvantage: - PG cramps - Infection. Split ejaculate The advances in IVF, ET. reviving IUI. History of IUI Abondoned (Stone et al, 1986)

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 +

Advantages of IUI 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)

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)

Selection + counseling or Protocol (spontaneous or stimulated cycle) Folliculometry & Endometrial thickness. Timing of insemination. Semen preparation. Procedure: IUI Steps

Complete work up of infertility: (Semenogram- midluteal progestrone - HSG + laparoscopy) Indications. Adequate counseling Confidence of husband. Religious Cost Failure & success Complications. Selection and counselling

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 MIFIC (22%). Controversy No evidence- based infertility data.

Factors affecting success of IUI Couple: (age,duration of infertility,cause of infertility,BMI). Therapies: Semen processing technique. Protocol of COH. Timing of insemination.

Timed intercourse versus IUI Probability of conception Natural cycles (IUI  ) COH cycles (IUI    ) ( Cochrane database 2000)

Spontaneous cycle protocol Cervical factor. Sexual dysfunction. -D monitor every 2 days. -Follicle mm hcg 10,000 u. -Insemination 36 h after hcg. -Pregnancy test (hcg in serum 2w after insemination).

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.

Ov. Stim. Protocol con.. TVS monitoring of follicular growth and endometrial developmentTVS monitoring of follicular growth and endometrial development -Baseline TVS (day 2 -3 of Menst.) -Serial TVS (day 7-8 of stimulation) -Follicle mm hcg 10,000 u. -Insemination 36 h after hcg. -Pregnancy test (hcg in serum 2w after insemination).

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

Rationale:- Concentration of progressively motile and morphologically normal spermatozoa intoConcentration of progressively motile and morphologically normal spermatozoa into a small volume of culture fluid. a small volume of culture fluid. seminal plasma (PG- lymphokines- cytokines - antigens - infectious matter).Elimination seminal plasma (PG- lymphokines- cytokines - antigens - infectious matter). Reduce the number of free oxygen radicals.Reduce the number of free oxygen radicals. Semen processing

Prior to insemination. Cusco’s speculum. Catheter (types) During insemination: Utero cervical angle Catheter insertion. Insemination (catheter withdrawal) After insemination Rest ?! Luteal phase support Procedure of IUI

Where IUI is done? Ideally in a clinic with IVF facilitiesIdeally in a clinic with IVF facilities (all services under one floor) -OHSS -IVF choice. -Freezing extra embryos.

Where IUI is done? IUI in the office setting Benefits: to 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.

Pre-Requisites for office IUI 1. Organization the practice to be extended in the week ends or holidays. 2. TVS probe ± Ovulation prediction kits. or 3. Office semen processing or RSP service (Remote Semen preparation). 4. Familiarity about the optimal time for referral the case to an infertility specialist.

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.

Recent advances: SIFT (Sperm Intrafallopian transfer) Speically designed catheters (Jansen- Anderson Catheter Sets) ORThe processed sperm can be injected into the tubes laparoscopically OR guided by ultrasound without anaesthesia or surgrey.

Conclusion This means that: 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.

T HANK YOU Prof. DR. MOHAMMAD EMAM Prof. OB& GYN, Mansoura Faculty of Medicine Member of Mansoura Integrated Fertility Center (MIFC) Telefax &