IUI/AIH
INDICATION
Ejaculatory Failure
Anatomica(hypospadias)
Neurological(spinal cord inury)
Retrograde Ejaculation(Multiple Sclerosis)
Psychological(Impotence)

CERVICAL FACTOR
cervical mucous hostility
poor cervical factor

MILD MALE SUBFERTILITY
Oligozoospermia/Asthenozoospermia/Teratozoospermia

UNEXPLAINED INFERTIITY
Endometriosis
Immunological factor
Ovuatory dysfunction with COH
HIV discordant couples

INDICATION OF AID/Insemination of donor sperm

Gross male subfertiity
-Obstructive Azoospermia
-Non obstructive AZoospermia
Severe Oligo/Astheno/Teratozoospermmia
Failed fertilization with ICSI
HIV Discordant couple
Familial /Genetic disease
Severe Rh incompatibility
Single female/lesbian couple

CONTRADICTION OF IUI

Duration of infertility> 7 yrs
Damage or blockage of both fallopian tube
Pelvic Endommetriosis stage 2
Peritubal adhesions
Severe male factor infertility
Genital tract infection
Severe abnormal semen parameter
Unexplained uterine bleeding

STEPS OF IUI

Selection of patient

OVARIAN STIMULATION
-Monitoriing of follicular growth & endometrial development
-Timing of insemination
-semen prepration
-IuI with prepared semen
-Luteal Phase Support

Stimulation of ovulation
Use of medicine to stimulate development of one or more mature follicle in anovulatory cycle.

SUPEROVUATION-Intentional production of many mature follicles in one cycle triggered by medication that stimulates ovaries in early follicular phase.

ADVANTAGE OF SUPEROVULATION + IUI

Subbtle ovulatory defect missed by standard testing may be overcome.

Increased no.of eggs for ovulation increases chance of pregnancy
Use of washed sperms increases deposition of motile sperms available to ovulated oocytes.

NATURAL CYCLE IUI

Monitoring TVS for follicular maturation

Once a mature follicle is 18-24 mm size endommetrium>9 mm,trilaminar –give HCG 5000 IU

-IUI –after 36-48 hrs after that.

COH+IUI

Nice Guideline 2004
Ovarian stimulation should not be offered when IUI is used to mmanage male factor & unexplained infertility.

Cochrane database 2006-IUI with OI inceases live birth compared with IUI alone.

TYPES OF OVARIAN STIMULATION

A)Induction of Ovuation-Use of medicine to stimulate development of one or more mature follicle in anovulatory cycle.

B)Superovulation-Intentional production of many mature follicles in one cycle triggered by medicine that stimulates ovaries in follicular phase.

C)Controlled Ovarian Hyperstimuulation(COH)-Regulated superovuation by turning off patient own Hormone(down regulation)-followed by stimulation

AIM-
1)Multiple follicular growth

2)Controlled timing of ovulation-Eggs can be surgically retrieved before they are ovulated.

3)prevention of premature LH Surge

ADVANTAGE OF SUPEROVULATION IN OVULATORY CYCLE

Subtle ovualatory defect missed by std.testing may be overcome
Inccreased no.of eggs available for fertilization increase chance of pregnancy.
Use of washed sperm increases density of motile sperms available to ovulated oocytes.

FOLLICLE DEVELOPMENT-An overview
Time to achieve pre ovulatory status in 85 days –majority(70 days) is independent of Hormones.

Cohort recruited at luteal-follicular transition
Follicuar phase 10-14 days.

Sequential action of Hormones & autocrine –paracrine factors.

Clomiphene citrate is non steroidal triphenylethylene derivative.

Estrogen Agonist & Antagonist

50-100 mg tab.

Oral D2-D6
Ovulation 70-92%
Conception rate 20-35%
SIDE EFFECCT
Transient hot flushes,vasomotor symptoms,mood flushes,headache
Breast tenderness,pelvic pressure or pain ,nausea,abdominal distension
Visual disturbance—blurred or double vision,scotoma,photosensitivity
OHSS ,Multiple pregnancy-5-8%

RCOG Guideline & ACOG Recommendation

Clommiphene should be used for max.12 months in a lifetime & maximum 6 month consequently.

OI in CC resistant cases

Weight loss
Gonadotrophin therapy
Insulin sensitizer
GnRH Analogue
Laparoscopic Ovarian Drilling
Aromatase inhibitor

CC Resistance(ovuation faiure)
Faiure to ovulate with 3 mts of use o CC upto 150 mg/day( 250 mg/day)x5 days
CC Failure(conception failure)
Pt who ovulates but failes to conceive.

Arommatase inhibitors(letrozole)

Gonadotrophins

FSH 75-100 IU daily D2/D3

IUI
E2-150-250 pg/ml for> 15 mm Follicle
IUI between D13-D16

Cancellation UI
> 6 Follicle > 15 mm
> E2>1500 Pg/mi

Single Vs Double IUI-No difference in result(Fert.sterl.2003)

IUI Vs TI-RCT 73 Pt

PR-4.3% Vs 2.4%

CC+IUI Vs CC

PR-8.3% Vs 5.6%

PR Gn +IUI Vs Gn alone

18% Vs 8%
ASRM Bulletin- Fertil Steril 2006
Bed Rest-10 min bed rest increases PR

Intercourse permissible

LUTEAL PHASE SUPPORT

HCG 2000 IU D3-D6
Or
Tab Duphaston 10 mg BD X 14 Days
Or
Micronised Progesterone 200 mg BDX 14 days