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In the Management of Subfertile Couples

Dr. JEHAD YOUSEF FICS, FRCOG

ALHAYAT ART CENTER AMMAN – JORDAN

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Objectives of the Presentation

To examine the current indications, clinical and

laboratory methodologies used in IUI and the impact of female and male factors on success.

Emphasis is centered in questioning the following: - The value of IUI against timed intercourse. - IUI application with or without COH. - Timing and frequency of IUI.

- Impact of various parameters on success.

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Artificial Insemination (A.I.H)

Intra-vaginal insemination (IVI) Intra-cervical insemination (ICI) Intrauterine insemination (IUI) Fallopian tube sperm perfusion (FSP) Sperm Intra-fallopian insemination (SIFI) Direct Intra-peritoneal insemination (DIPI) Intra-follicular insemination (IFI)

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Intrauterine Insemination

The rationale is that increasing the density of both eggs and sperm near the site of fertilization will increase the likelihood of pregnancy.

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Indications for IUI

• The impossibility of vaginal ejaculation

- psychogenic or organic impotence

- severe hypospadias, retrograde ejaculation

- cry preservation of sperm in cases of cancer treatment.

• Abnormal male factor

- oligospermia - asthenospermia - teratospermia• Unexplained infertility• Cervical factor infertility• Husband is away from wife for

long time (work abroad)• HIV negative women with

processed semen of HIV +ve husband.

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IUI : Step by Step

Patient’s selection Natural cycle or Controlled Ovarian stimulation. Monitoring of treatment, to measure the growth of

follicles, individualize drug doses, and prevent hyper stimulation.

Sperm preparation Insemination Luteal support.

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Selection of patients

A Valid indication for IUI Normal or mildly abnormal semen parameters (Semen analysis

within 3 months of the planned IUI) No evidence of intrauterine disease and patent tubes

(at least one) as shown in a Recent HSG or (laparoscopy / hysteroscopy)

Female age < 43 years ? (Day 3 FSH < 10-15 mIU/Ml, if age > 37 yrs)

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Protocol of natural cycle IUI

Monitoring begins 16 days before expected menses by TVS for follicular maturation.

Once a mature sized follicle of 18-24 mm & > 9mm trilaminar endometrium are obtained the woman will monitor urinary LH every 4-5 hours.

Intrauterine insemination is timed 36-40 hours from the LH surge and will be repeated within 12 hours if the oocyte had not released as yet.

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Controlled ovarian hyperstimulation before IUI

• Number of oocytes available

( chance of fertilization )

• Steroid production

( chance of implantation )

• It may correct subtle ovulatory disorders, such as luteinized unruptured follicle syndrome, not detected with routine diagnostic studies

• More exact time to ovulation and insemination can be determined

The rationale

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- Menses is the marker for onset of uterine/endometrial cycle. - inter-cycle FSH is the marker for functional onset of ovarian cycle.- Only those antral follicles which coincide with the inter-cycle rise in

FSH can enter the final stages of follicular growth

ovul

atio

n

ovul

atio

n

Intercycle

FSH

•

Synchronization of the menstrual cycle

Brown 1978

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Synchronization of the menstrual cycle

Controlling the timing of occurrence of inter-cycle increase in FSH :

Timely use of E2 (2 mg estradiol valerate, PO BID starting 3 days before the onset of menses of the previous cycle.

Short-term use of the OC pill for 7 to 21 days in the cycle preceding stimulation cycle.

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Clomiphene citrate or similar drugs

u-hMG or highly purified u-hMG

Purified u-FSH or highly purified u-FSH

Recombinant (r-FSH)

Combinations

----------------------------------------------------------------------

GnRH agonists in combination with hMG and/or FSH (long, short or ultra short protocol)

GnRH antagonists in combination with hMG and/or FSH (fixed or variable protocol)

Ovarian Stimulation Protocols

1313 Which ovarian stimulation to chose before intra-uterine insemination?

Drug Cost; Drug availability and Patient acceptability CC is an effective alternative for young women with good

prognosis, whereas in the remaining cases hMG or FSH would be the preferable drug.

rFSH Vs Urinary preparations : No difference in clinical pregnancy rate.

There is no advantage in routinely using GRh-a in conjunction with gonadotrophins for ovulation stimulation

At the moment one should use the least expensive medication.

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Monitoring ovarian stimulation

Transvaginal ultrasound scanning : . No. & size of follicles . Pattern & thickness of endometrium Estrogen blood level

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Endometrial thickness & Monitoring ovarian stimulation

0

500

1000

1500

2000

2500

3000

3500

0 5 10 15 20Endometrium (mm)

E 2(pmol/L)

After Zeev Shoham

n = 183

Correlation between E2 and endometrial thickness

1616 Optimum ovarian stimulation

For IUI 2 - 4 follicules with Ø 18 – 19 mm. Estradiol blood level :

150-250 pgm / ml per 15 mm follicle. Endometrium 9 mm thick & trilaminar. IUI between Cycle D13 and D16.

Cancellation : 6 follicles 15 mm irrespective of E2 level Estradiol 1500 pg/ml.

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Sperm processingRationale

Concentration of progressively motile and morphologically normal spermatozoa into a small volume of culture fluid.

Elemination of seminal PG, lymphokines, cytokines and infectious agents

Reduce the number of free oxygen radicals.

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Sperm processing

Simple Sperm wash Swim-up following sperm wash

once or twice. Density gradient column

separation (filtration in Percoll gradients, PureSperm or Isolate).

Adding chemicals to the washed sperms (caffeine , pentoxyfylline, 2-deoxyadenosine, kallikrien, bicarbonate, platelet activating factor) ??

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Sperm processing

Samples with an acceptable number of motile sperm ( > 20 millions / ml ) can be processed efficiently by sperm wash twice and swim-up.

Poor quality semen samples should be processed using density gradient centrifugation DGC.

Morshedi M et al, 2003

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Timing and Frequency of IUI

Fixed protocol:• Single insemination: 36 – 40 hrs post – hCG • double insemination: within 12 & 48 hrs post - hCG

Variable protocol:• TVS 36 h post hCG:- Ovulated single IUI

- Not Ovulated IUI at once IUI 24 hrs

later

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IUI technical aspects

- Partially filled urinary bladder; lithotomy position & abdominal US

- Gently and atrumatically clean the cervix with saline soaked swab

introduce IUI catheter through cervix; no touch to fundus

- Slowly inject 0.3-.05 ml of processed semen

- Slowly withdraw catheter

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Management following IUI

Bed rest A 10 minutes bed rest after IUI has a positive effect on PR.

Intercourse within 12-18 hours of IUI. Luteal phase support, OPTIONS:

- hCG: 1.500 IU hCG 3 & 6 days after 1st hCG

- Duphastone 10 mg PO / 8 hourly after IUI x 14 days

- Cyclogest 400 mg supp. PV or PR; once daily after IUI x 14 days

- Utrogestan: 100 mg PV / 8 hourly after IUI x 14 days

2323 Evidence based recommendations for

practicing IUI Grade A recommendations*

Couples with mild male factor fertility problems, unexplained fertility problems or minimal to mild endometriosis should be offered up to six cycles of intra-uterine insemination because this increases the chance of pregnancy.

NICE Guidance Feb. 2004

* Grade A : based on randomised controlled trials

2424 Evidence based recommendations for

practicing IUI Grade A recommendations

Where intra-uterine insemination is used to manage male factor fertility problems, ovarian stimulation should not be offered because it is no more clinically effective than unstimulated intra-uterine insemination and it carries a risk of multiple pregnancy.

NICE Guidance Feb. 2004

2525 Evidence based recommendations for

practicing IUI Grade A recommendations

Where intra-uterine insemination is used to manage unexplained fertility problems, both stimulated and unstimulated intra-uterine insemination are more effective than no treatment. However, ovarian stimulation should not be offered, even though it is associated with higher pregnancy rates than unstimulated intra-uterine insemination, because it carries a risk of multiple pregnancy.

NICE Guidance Feb. 2004

2626 Evidence based recommendations for

practicing IUI Grade A recommendations

Where intra-uterine insemination is used to manage minimal or mild endometriosis, couples should be informed that ovarian stimulation increases pregnancy rates compared with no treatment, but that the effectiveness of unstimulated intra-uterine insemination is uncertain.

NICE Guidance Feb. 2004

2727 Evidence based recommendations for

practicing IUI Grade A recommendations

Where intra-uterine insemination is undertaken, single rather than double insemination should be offered.

Where intra-uterine insemination is used to manage unexplained fertility problems, fallopian sperm perfusion for insemination (a large-volume solution, 4 ml) should be offered because it improves pregnancy rates compared with standard insemination techniques.

NICE Guidance Feb. 2004

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Number of trials of IUI ?

Pregnancies resulting from IUI occur during early treatment cycles.

Eighty-eight percent of pregnancies occur in the first three cycles of IUI and 95.5% within the first four cycles (Morshedi M et al, 2003).

Continued IUI beyond four trials

is not recommended

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Measures to improve results

Use of Aspirin in IUI Cycles Hsieh YY et al, 2000 RCT: Higher pregnancy rate and better endometrial pattern were achieved in patients with thin endometrium after aspirin administration.

Type of catheter Smith et al, 2002, RCT : No difference in PR when using softer Wallace catheter or the less

pliable Tomcat catheter Vaginal misoprostol at the time IUI Brown et al. 2001 RCT :

200 - 400 μg of misoprostol vaginal insertion at the time

of insemination is associated with higher PR.

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Measures to minimize risk ofOHSS

Shalev E, et al, 1995 RCT : s.c. injection of 0.1 mg GnRHa (decapeptyl) instead of hCG in IUI treatment cycles at high risk of OHSS.

De Geyter, et al 1996 RCT : Transvaginal aspiration of supernumerary follicles (more than three follicles sized > 14 mm) does not reduce the PRs and reduce multiple pregnancy rate.

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What is the upper age limit for IUI ?

Most studies have suggested that it is an effective treatment option for women under the age of 40 yrs

Success of intrauterine insemination,in women aged 40-42 years, Hawbe, et al,

Fertility and Sterility, Vol 78, No 1, July 2002

These researchers found in their review that it may be

a reasonable approach for women under the age of 43.

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Where IUI should be done?

Although IUI can be performed in an optimized office but Patients need to run from gynecologist to the lab. Fragmented care because of poor coordination.

Ideally in an optimized clinic in cooperation with an IVF unit

- IVF choice & Freezing any extra embryos in case of over-response

- ? Selective follicular reduction in case of over-response

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SUMMARY

IUI is relatively simple, non-invasive, cheap & easily repeatable.

Careful selection of patient is important. There is good evidence in the literature in favor of IUI as a

cost-effective treatment for unexplained and mild, moderate male factor sub fertility.

Although it may take relatively more treatment cycles to achieve pregnancy, there are considerable advantages to the patient in terms of risk / benefit ratio and financial cost as compared with other ARTs.

Failure of 4 - 6 trials of Gn. stimulated IUI in unexplained or mild male infertility, is an indication for IVF.

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Dr. J.Yousef FICS,FRCOGe-mail : ramoamman@yahoo.co.uk