1. EVALUATION OF ROLE OF INTRAUTERINE INSEMINATION (IUI) IN INFERTILITY
SUJOY DASGUPTA
Purvita Dam
Jhantu Kr Saha
Prof P S Chakravorty

2. INFERTILITY
“Infertility is a disease. The duration of failure to conceive should be ≥12 months before an investigation is undertaken unless medical history and physical findings dictate earlier evaluation and treatment” *
Monthly fecundity rate in general population is only 15-20%**
*American Society of Reproductive Practice Committee; Hum Reprod 2004;19:
**Federation CECOS. N Eng J Med 1982;206(7):404-6

3. EITIOLOGY OF INFERTILITY

4. OPTIONS FOR THE COUPLES
Medical Management
Surgical Management
Artificial Insemination (AI)
IUI
Intravaginal Insemination
Intracervical Insemination
Direct Intraperitoneal Insemination (DIPI)
Fallopian Tube Sperm Perfusion (FSF)
Direct Intrafollicular Insemination (DIFI)
Assisted Reproductive Techniques (ART)
IVF-ET
GIFT, ZIFT
ICSI
POST
Third Party Reproduction
Adoption

5. Intrauterine Insemination (IUI)
Washed sperm (of the male partner or the donor) is introduced in the uterine cavity in proper time
First used by John Hunter, 1770
Mechanisms
Eliminates toxins, bacteria, free radicals present in seminal plasma
Bypasses hostile vaginal acidic pH and cervical mucus
Shortens the distance travelled by the sperms to reach the site of fertilization
Overcomes faulty coital technique

6. Aims and Objectives The pregnancy rates per cycle of IUI
The pregnancy rates per couple (undergoing IUI)
Prognostic factors associated with successful IUI
Adverse effects of IUI (if any)

7. MATERIALS AND METHODS

8. STUDY AREA STUDY PERIOD STUDY DESIGN STUDY POPULATION
Deptt of Obstetrics and Gynaecology,
Eden Hospital,
Medical College and Hospital, Kolkata
STUDY PERIOD
1 year (1st June, st May, 2012)
STUDY DESIGN
Observational Longitudinal Study
STUDY POPULATION
Infertile couples attending the
Infertility clinic, who conform to the inclusion criteria

9. STUDY DESIGN Inclusion Criteria
Female partner years
Regular frequent unprotected intercourse >1 year but unable to conceive
Male factors -
Anatomic defects of penis
Sexual dysfunction
Mild & moderate oligozoospermia (sperm concentration 5-20 x 106/ml)
Mild asthenozoospermia (<50% sperms showing fast forward and slow progressive motility)
Mild teratozoospermia (morphologically normal sperm 4-15% according to Kruger’s strict criteria)
Female factors -
Anatomic defects of vagina or cervix
Minimum to mild endometriosis (AFS score ≤15)
PCOS (defined according to Rotterdam Consensus, ESHRE and ASRM)
Other causes of anovulation
Unexplained infertility
All the above factors not responding to conventional medical/ surgical treatment, wherever possible

10. Exclusion Criteria Female factors- Male factors-
Bilateral tubal blockage
Pelvic tuberculosis
Severe pelvic endometriosis
Male factors-
Azoospermia (No sperm in the ejaculate, confirmed in three properly collected samples)
Severe oligo-astheno-terato-zoospermia(Sperm density <5 x 106/ml, No motile sperms in the sample, <4% sperm morphologically normal according to Kruger’s strict criteria)
Retrograde ejaculation and anejaculation

11. STUDY TECHNIQUE Female Partner- USG, HSG/Laparoscopy,
Informed Consent
Both partners- History, Physical Examinations, Routine Blood, Serology
Male Partner- Semen Analysis
Female Partner- USG, HSG/Laparoscopy,
Hormonal assay (as needed)
Ovulation Induction – Clomiphene Citrate, HMG/FSH- as indicated

12. STUDY TECHNIQUE (Contd.)
TVS- Follicular size & number,
-Endometrial Thickness
Ovulation triggering by hCG
IUI (H) after 36 hours of hCG Injection (Single Insemination)
Husband’s Semen Collection
Semen Preparation- Swim-up Technique
-Ham’s F-10 medium

13. STUDY TECHNIQUE (Contd.)
Insemination - IUI Catheter
-Disposable Speculum
Progesterone for Luteal Support
Follow up- Menstrual H/O, Urine for Pregnancy Test
Couple with Failed IUI- Repeat IUI up to Maximum Six Cycles
Successful IUI- Followed up throughout the Pregnancy

14. RESULTS

15. TOTAL NUMBER OF IUI CYCLES
Number Of COUPLES
Total Number Of CYCLES
One 10
Two 14 28
Three 18 54
Four 6 24
Five 3 15
Six 2 12
TOTAL 53
143

16. AGE DISTRIBUTION OF THE COUPLES

17. AGE DISTRIBUTION OF THE COUPLES

18. URBAN/ RURAL DISTRIBUTION OF THE COUPLES

19. SOCIO-ECONOMIC STATUS OF THE COUPLES

20. DURATION OF INFERTILITY OF THE COUPLES

21. PAST OBSTETRIC HISTORY OF THE WOMEN

22. CAUSE OF INFERTILITY OF THE COUPLES

23. INITIAL SEMINAL PARAMETERS OF MALE PARTNERS
Number Of Male Partners
(n = 53)
Percentage (%)
Mean ± SD
Sperm density (per ml)
≥20 x 106 36
67.92
38.04 ± 24.34
≥10 x 106
<20 x 106 10
18.87
≥5 x 106
<10 x 106 7
13.21
Normal sperm morphology
≥15%
22.19 ± 11.72
≥10%
<15% 9
16.98
≥4%
<10% 8
5.10
Sperm motility
≥50% 32
60.38
53.75 ± 9.98
<50% 21
39.62

24. INSEMINATING MOTILE SPERM COUNT (IMSC)

25. OVARIAN RESPONSE TO THE DRUGS USED FOR OVULATION-INDUCTION

26. ENDOMETRIAL THICKNESS

27. OUTCOMES OF IUI IN TERMS OF PREGNANCY
Total Number of Couples
Total Number of IUI Cycles
Number Of Pregnancy After IUI
Reported Live Birth 53
143 14 8
Pregnancy Rate Per Cycle of IUI
Cycle Fecundability
9.79%
Pregnancy Rate Per Couple
26.42%
Live Birth Rate Per Cycle of IUI
(Reported)
Cycle Fecundity
5.59%

28. OUTCOMES OF PREGNANCY AFTER IUI

29. RELATIONSHIP BETWEEN PREGNANCY AND NUMBER OF IUI CYCLES

30. RELATIONSHIP BETWEEN PREGNANCY AND AGE OF THE WOMEN

31. RELATIONSHIP BETWEEN PREGNANCY AND AGE OF THE MEN

32. RELATIONSHIP BETWEEN PREGNANCY AND DURATION OF INFERTILITY

33. RELATIONSHIP BETWEEN PREGNANCY AND TYPE OF INFERTILITY

34. RELATIONSHIP BETWEEN PREGNANCY AND INITIAL SEMINAL PARAMETERS

35. RELATIONSHIP BETWEEN PREGNANCY AND INITIAL SEMINAL PARAMETERS (Contd.)

36. RELATIONSHIP BETWEEN PREGNANCY AND INITIAL SEMINAL PARAMETERS (Contd.)

37. RELATIONSHIP BETWEEN PREGNANCY AND IMSC

38. RELATIONSHIP BETWEEN PREGNANCY AND OVARIAN RESPONSE

39. RELATIONSHIP BETWEEN PREGNANCY AND ENDOMETRIAL THICKNESS

40. POST-IUI COMPLICATIONS

41. COMPLICATIONS OF POST-IUI PREGNANCIES

42. DISCUSSION

43. Why Six Cycles? Studies showed-
most women conceive after 4-6 cycles of IUI
cycle fecundability declines by ½ to 2/3 thereafter 1,2
The NICE fertility guidelines - up to 6 IUI cycles for patients with unexplained infertility, male subfertility, cervical factor and minimum to mild endometriosis 3
In Our Study-
Most women conceived after 3rd cycle
No pregnancy was reported after 6th cycle
Ragni G et al. Fertil Steril. 1999;72(4):619-22
Khalil MR et al.; Acta Obstet Gynaecol Scand Jan, 80(1): 74-81
National Institute of Clinical Excellence. Fertility: Clinical guidelines. No 11. London: Abba Litho Ltd. UK, 2004

44. Cycle fecundability- the probability that a cycle will result in pregnancy
Cycle fecundity- the probability that a cycle will result in a live birth
Various studies- IUI cycle fecundity- 3-10% 1-3
In Our Study- at least 5.59%
Miller D et al. Urology 2002;60:497
Van der W LA et al. J Asst Reprod Gen 1998;15:359-64
Ford WC et al. Baillieres Clin Obstet Gynaecol 1997;11:691
Studies
Fecundability Per CYCLE
Fecundability Per COUPLE
Steven R B et al (2008)
4-18%
Haebe J et al (2002)
4-15%
Guzick et al (1999)
18%
Nulsen et al (1993)
19.3%
Martinez AR (1990)
11.9%
20%
Our Study
9.79%
26.42%

45. DETERMINANTS OF IUI OUTCOME
Age of the Women
Steven R B et al (2008) - Maximum success, if <25 years
Marviel et al (2010) – Maximum conception, if <30 years
Badawy et al (2009)- Little success, if >35 years
In our study-
Maximum success years (22.22%)
Declines progressively with increased age
Age of the Men
Mathieu C et al (1995)- Increased age adversely affects outcome
In our study- Maximum success years (33.33%)

46. DETERMINANTS OF IUI OUTCOME (Contd.)
Duration of Infertility
Mathieu C et al (1995)- Highest rate when <3 years
Nuojua-H S et al (1999)-
Duration <6 years- conception rate 20%
Duration >6 years- conception rate 10%
In our study-
Highest success rate if ≤3 years
Then declines rapidly

47. DETERMINANTS OF IUI OUTCOME (Contd.)
Type of Infertility
Dickey et al (2002)- maximum success for ovulatory dysfunction, followed by male subfertility
Khalil MR et al (2001)- Best results in anovulation and unexplained infertility
In our study-
The best result in PCOS (25%)
Followed by unexplained infertility (20%)
And male subfertility (10.81%)

48. DETERMINANTS OF IUI OUTCOME (Contd.)
Initial Seminal Parameters
Haebe J et al (2002)- Higher success with
total motile sperm count >2 million
post wash motility >40%
normal sperm morphology >4%
Montanaro GM et al (2001)-
Pregnancy rates 18.2% when normal sperm morphology >10%
Pregnancy rates 4.3% when normal morphology <10%
Lee RK et al (2002)-
Best results with normal morphology >14%
Poor when fewer than 4% sperms were normal.
Shulman et al (1998)- Higher success with motility>30%
In our study- The best results were obtained when
sperm density x 106/ml
10-15% sperms had normal morphology
>50% sperms had normal motility

49. DETERMINANTS OF IUI OUTCOME (Contd.)
Ovarian Response
Endometrial Thickness
Various Studies-
Contradictory results 1-3
In our Study- Best results when thickness is 7-9 mm
Abdalla HI et al. Hum Reprod 1994;9:363-5
Basil S. Ultrasound Obstet Gynecol 2001;18:258-6
Seddigheh E et al. Fertil Steril 2006;88:432-37
Number of Follicles
Pregnancy rates
Iberico et al (2004)
Our Study
One
6.2% %
Two
12.9% %
Three
30.0% %

50. COMPLICATIONS OF IUI
Important complications- Mild OHSS and multiple pregnancy were observed in 22.30% and 0.70% of total cycles respectively
Wang JX et al (2002)- higher incidence of preterm birth associated with IUI pregnancies
In our study- preterm birth rate at least 21.43%
Nuoja HS et al (1999)- No increased congenital anomaly of the offspring
In our study- no congenital anomaly was reported

51. CONCLUSION

52. IUI can make many infertile couples feel the taste of parenthood
Proper case selection is important before useless wastage of money, time, energy and resources
If there is no conception after 6 cycles, the investigations should be reviewed and alternatives should be considered
The prognostic factors should be kept in mind before IUI and should be discussed with the couples
Can safely be conducted in hospitals with relatively low resources

53. THANK YOU