Intrauterine insemination - techniques

intra uterine insemination

1. Intrauterine insemination

2. Infertility, defined as inability to conceive after 6 months of unprotected intercourse Intra uterine isemination is the process of placing washed spermatozoa transcervically into the uterine cavity Compared to other ART , IUI is simple and less expemsive Safe and relatively easy procedure

3. Indications Unexplained infertility Mild male factor oligo/ astheno / teratozoospermia Endometriosis Immunological factors cervical , seminal Ejaculatory failure neurological , anatomical , psychogenic

4. With sperm count < 5 million , or patients with more than 1 abnormal sperm parameter, ICSI is more acceptable Tubal disease is not an indication for IUI In patients with ejaculatory failure (severe hypospadias ,retrograde ejaculation and impotence) , IUI success rates depends on sperm quality In patients with progressive sperm motility of 20-30 % prognosis is good .

5. Cervical factor infertility – PCT ( post coital test ) , for assessing the sperm motility in a sample of post coital cervical mucous PCOS – induction of ovulation with IUI - pregnancy dates found to be 11-20% Thes are tried in women with PCOS who failed to conceive despite successful OI

6. Factors influencing IUI outcome Age of female partner – pregnancy rates were 24 % with age < 35 years 18 % 35-37 years 15.1% 38-40 years 1.8% > 40 years Duration of infertility – decrease in pregnancy rates if duration of infertility is high Aetiology – lower pregnancy rates with endometriosis Number of IUI cycles – most pregnancy occurred between 3-6 IUI cyclesm

7. No evidence that double insemination give rise to higher live birth rates 33 % pregnancy rates for combined IUI and OI 18% for IUI alone

8. Ovulation induction for IUI Empiric ovarian stimulation with clomiphene citrate or exogenous gonadotropins is commonly combined with IUI in the treatment of couples with male factor infertility cycle fecundability (probability of pregnancy per cycle) is higher after combined treatment than after IUI or ovarian stimulation alone in couples with unexplained infertility.

9. When male factor infertility is the diagnosis, and ovulatory function is normal, treatment with IUI alone is reasonable and appropriate. When IUI in spontaneous cycles or indicated clomiphene-induced cycles fails (approximately 3–4 cycles) or when the female partner is over age 35, exogenous gonadotropin stimulation may be expected to improve the likelihood for success.

10. Sperm Preparation The most common methods include conventional washing, the “swim-up” procedure, and density gradient centrifugation. Both the conventional washing and swim-up methods allow sperms to remain in contact with dead or defective sperms and leukocytes, which produce high levels of reactive oxygen species that may cause oxidative damage to sperms membranes and motility. D ensity gradient centrifugation, glass wool filtration are more effective to remove dead cells

11. Washing The simplest method of washing sperms involves diluting the liquefied semen sample in buffered medium in a sterile tube (1:1–1:3, depending on volume), followed by low-speed centrifugation (200–300g for approximately 10 minutes) and removal of the supernatant. After two or more cycles, the final pellet is resuspended in a small volume (approximately 0.5 mL) of medium for insemination. Sperm washing yields the greatest numbers of sperms, but the final specimen also contains dead and abnormal sperms and other cellular debris

12. SWIM UP The final pellet is gently overlaid with 0.5–1.0 mL of fresh medium and incubated at 37°C for 30–60 minutes, allowing the most motile sperms to swim up into the supernatant. The method generates a cleaner specimen, devoid of dead sperms and other cellular debris, but also yields significantly lower numbers of sperms

13. DENSITY GRADIENT CENTRIFUGATION The typical methodology for density gradient centrifugation involves overlaying the liquefied ejaculate on a column of higher-density media that are layered to create a gradient of increasing density from the top to the bottom of the column, followed by low-speed centrifugation for 15–30 minutes. The most highly motile sperms traverse the gradient more rapidly and can be recovered from the soft pellet at the bottom. The method also appears to select a population of sperms with normal morphology

14. Timing and Technique IUI should be timed to coincide with the time of spontaneous or induced ovulation. Normal sperms can survive in the female reproductive tract and retain the ability to fertilize an egg for at least 3 days, but an oocyte can be successfully fertilized for only approximately 12–24 hours after it is released. In normal fertile couples, the probability of conception rises progressively over an interval of 5–6 days and peaks when intercourse occurs on the day before or day of ovulation

15. Cryopreservation damages sperms, The timing of IUI in the treatment of male factor infertility is therefore far more critical for success than the timing of natural intercourse in infertile couples, regardless whether infertile partner sperms or frozen donor sperms are used. In natural and clomiphene-stimulated cycles, the most practical and reliable method for timing IUI involves urinary LH monitoring beginning approximately 3 days before expected ovulation and insemination on the day following detection of the LH surge.

16. When ovulation is triggered by injection of exogenous hCG in natural or stimulated cycles, IUI generally is best performed approximately 34–40 hours later. Immediately before performing IUI, removal of any excess mucus that might clog the catheter tip is recommended. The tip of the insemination catheter is then simply inserted into the cervical os and advanced slowly into the uterine cavity. The insemination specimen (approximately 0.5 mL) should be introduced slowly over 10–30 seconds.

17. Donor Sperms R equire extensive screening of prospective sperm donors before acceptance. Semen quality, to include an evaluation of sperm viability and motility after a trial freeze and thaw, excludes approximately 75% of all candidates. Personal health history and physical examination, family medical history, genetic screening for cystic fibrosis and other carrier states (depending on ethnicity), S creening for sexually transmitted infections (syphilis, gonorrhea, Chlamydia, cytomegalovirus, hepatitis B and C, HIV types I and II, and human T-lymphocytic virus [HTLV] types I and II

18. sperm specimens must be quarantined and cannot be released for use unless they have remained sequestered for at least the 180 days preceding the most recent negative test for HIV As when using infertile partner sperms, the likelihood of success with therapeutic donor insemination increases with the number of motile sperms in the specimen and is greatest when the count exceeds 20 million. Most sperm banks guarantee a minimum number of motile sperms in each specimen .