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)

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)

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.

Indications for IUI-H 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 Cont... 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.

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

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

Questions remain to be answered (Evidence - based fertility ???) Which type of couples with male subfertility benefit most from COH + IUI ?

? ? ? Cont.. Is IUI and /or COH cost effective for male subfertility compared with IVF? 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

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

Pre-requisities Optimizing the office. Optimizing the knowledge.

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.

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.

Pre-requisities cont…. Optimizing The Knowledge For IUI: The gynecologist should be aware of: Indications Be sure that: Women not have a concomitant condition that would prevent successful insemination. 2. Semen processing.

Semen processing 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.

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).

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.

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.

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)

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.

Most who will benefit are: Conclusions 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. Most who will benefit are:

Conclusion cont… For practicing IUI as an office procedure pre-requisities regarding optimization of the office and knowledge of gynecologists should be present

Conclusions cont… 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.

Thank you Prof. DR. MOHAMMAD EMAM OB& GYN, Mansoura Faculty of Medcine Mansoura Integrated Fertility Center (MIFC) EGYPT Telfax 0020502319922 & 0020502312299 Email. mae335@hotmail.com