WHEN TO MOVE FROM IUI TO IVF WHEN TO MOVE FROM IUI TO IVF? Dr(Brig) R K Sharma VSM DIRECTOR HOD IRMIC

IUI Effective , non invasive, relatively simple & inexpensive method of treatment. Can be provided easily in simple setups.

INDICATIONS OF IUI Mild to moderate Endometriosis Unexplained infertility Anovulatory infertility Cervical infertility Immunological abnormalities Mild degrees of male factor infertility Non-consummation of marriage due to – ED/vaginismus

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

*IVF results depend upon the clinic Approximate chance for success getting pregnant with one month of various treatments Female age under 35, 2 years of trying to conceive Type of Treatment Total Motile Sperm Count (in millions) Less than 1 1-5 5-10 10-20 > 20 Intercourse 0.2% 1% 2% 2.5% 3% IUI 0.4% 4% 5% 7% Clomid plus IUI 0.5% 9% FSH plus IUI 6% 12% In Vitro Fertilization - IVF with ICSI* 40% *IVF results depend upon the clinic

THE IMPACT OF THE TOTAL MOTILE SPERM COUNT Pregnant group 38.7 x 106 Non pregnant group 28.6 x 106 Significance was reached when the total motile sperm count exceeded 5 x 106. The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa. Huang HY, et al. J Assist Reprod Genet 13: 1, 56-63, Jan, 1996

THE IMPACT OF THE TOTAL 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. 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

SPERM QUALITY NECESSARY FOR SUCCESSFUL INTRAUTERINE INSEMINATION Initial sperm motility  30% The total motile sperm count  5 X 106. When initial values are lower, IUI has little chance of success 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

IMPACT OF SPERM MORPHOLOGY 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). 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

ADVANCED SEMEN ANALYSIS - HIGHLY PREDICTIVE OF IUI SUCCESS The number of motile normal sperm available for insemination 24-hour survival rate. Advanced semen analysis: a simple screening test to predict intrauterine insemination success. Branigan EF, et al. Fertil Steril 1999 Mar;71(3):547-51

SPERM-PREPARATION TECHNIQUES- IUI RESULTS Abnormal semen analyses. Density gradient is superior to the swim-up technique in improving AR, HOS and nuclear maturity 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

IMPACT OF NUMBER OF IUI PER CYCLE Pregnancy rate significantly higher with increasing the number of IUI per cycles, being 24.1% and 11.8% in two IUI per cycles and one IUI per cycle respectively 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

Single iui better cochrene 2009

IMPACT OF INFERTILITY DURATION ON IUI RESULTS Pregnancy rate decreased with increasing infertility duration. Zhao Y, et al. Impact of semen characteristics on the success of intrauterine insemination. J Assist Reprod Genet. 2004 May; 21(5): 143-8

Age and number of eggs Faddy et al., 1992

Impact of advancing female age on IVF success 2005 CDC IVF Report – Impact of advancing female age on IVF success

IMPACT OF IUI ATTEMPTS Most pregnancies 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, it may be more reasonable to try several more cycles (6-9 cycles total). Plosker SM, et al. Predicting and optimizing success in an intra-uterine insemination programme. Hum Reprod. 1994 Nov; 9(11): 2014-21

CC / OVARIAN CANCER Incidence of ovarian cancer in women taking CC was about three times greater than the expected incidence for the general population. Rossing MA, et al. Ovarian tumours in a cohort of infertile women. N Engl J Med 1994;331:771–776 . 

CC / OVARIAN CANCER No significant difference between the observed incidence of ovarian cancer in women treated with CC and the expected incidence in the general population Venn A, Watson L, Bruinsma F, et al. Risk of cancer after use of fertility drugs with in-vitro fertilisation. Lancet 1999;354:1586–1590. Parazzini F, Negri E, La Vecchia C, et al. Treatment for infertility and risk of invasive epithelial ovarian cancer. Hum Reprod 1997;12:2159–2161.  Mosgaard BJ, Lidegaard O, Kjaer SK, et al. Infertility, fertility drugs, and invasive ovarian cancer: a case-control study. Fertil Steril 1997;67:1005–1012.  Shushan A, Paltiel O, Iscovich J, et al. Human menopausal gonadotrophin and the risk of epithelial ovarian cancer. Fertil Steril 1996;65:13–18. 

CAUTION Prolonged use of clomiphene citrate may be associated with an increased risk of a borderline or invasive ovarian tumour.

SPECIAL SITUATIONS Evidence of impending OHSS during IUI Add antagonist and convert to IVF

RISK FACTORS FOR POOR OUTCOME WITH IUI Advanced female age Poor postwash sperm motility History of corrective pelvic surgery Poor postwash sperm motility in combination with either of these other two risk factors resulted in no successful pregnancies 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, no5, pp. 245-252 

Mehdi Benchaib et al.Reproduction Vol.18, No.5 pp. 1023±1028, 2003 Sperm DNA fragmentation decreases the pregnancy rate in an assisted reproductive technique Mehdi Benchaib et al.Reproduction Vol.18, No.5 pp. 1023±1028, 2003

Patient may have normal semenology and have high DFI (DNA fragmentation index) or a very poor count and motility ,yet betterDFI.

Many cases of unexplained infertility who are unable to conceive by IUI,IVF/ICSI can do better after treatment of causative factors of abnormal DFI or by testicular extraction of sperm and ICSI

NOW REASONS FOR THE CLINICIAN TO MOVE FROM IUI TO IVF

WHEN MORE THAN 05 IUI CASE MONTH 400 CASES OF IVF/YEAR-COST EFFECTIVE

WHEN YOU WANT TO BE DIFFERENT

When you get information that your competitor is planning to open an IVF Centre

When you are able to fish an embryologist from others pond

IMPORTANT Each centre should define its policy which takes into account Diagnostic laboratory techniques available, Selection of the SPERM PREP technique Pregnany rates achieved Sensibility of the treated population Health care characteristics DECIDE -WHEN TO MOVE FROM IUI TO IVF?

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