Post on 13-May-2023
“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;19:1497-501
**Federation CECOS. N Eng J Med 1982;206(7):404-6
Medical Management Surgical Management Artificial Artificial
Insemination (AI)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-ETGIFT, ZIFTICSIPOST
Third Party Reproduction
Adoption
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
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)
STUDY AREASTUDY AREADeptt of Obstetrics and Gynaecology, Eden Hospital,Medical College and Hospital, Kolkata STUDYSTUDY PERIODPERIOD 1 year (1st June, 2011- 31st May, 2012)
STUDY DESIGNSTUDY DESIGNObservational Longitudinal Study
STUDY POPULATIONSTUDY POPULATION Infertile couples attending the Infertility clinic, who conform to the inclusion criteria
1. Female partner- 20-40 years
2. Regular frequent unprotected intercourse >1 year but unable to conceive
3. 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)
4. Female factors - Anatomic defects of
vagina or cervix Minimum to mild
endometriosis (AFS score ≤15)
PCOS (defined according to Rotterdam Consensus, 2003- ESHRE and ASRM)
Other causes of anovulation
5. Unexplained infertility
6. All the above factors not responding to conventional medical/ surgical treatment, wherever possible
Exclusion Criteria1.Female factors- Bilateral tubal blockageBilateral tubal blockage Pelvic tuberculosisPelvic tuberculosis Severe pelvic endometriosisSevere pelvic endometriosis
2.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
TOTAL NUMBER OF IUI CYCLESTOTAL NUMBER OF IUI CYCLESNumber Of IUI Cycles
Number Of COUPLES
Total Number Of CYCLES
One 10 10Two 14 28
Three 18 54Four 6 24Five 3 15Six 2 12
TOTAL 53 143
AGE DISTRIBUTION OF THE AGE DISTRIBUTION OF THE COUPLESCOUPLES
0
5
10
15
20
25
30
20-25 26-30 31-35 36-40
6 (11.32% )11(20.75% )
28 (52.83% )
8(15.10% )
Number O
f Wom
en (%
)
Age In Years
AGE O F FEM ALE PARTNERS
n=53
AGE DISTRIBUTION OF THE AGE DISTRIBUTION OF THE COUPLESCOUPLES
05
10
15
20
25
30
35
40
45
50
≤25 26-30 31-35 36-40 >40
2 (3.77% )7 (13.21% )
15 (28.30% )25 (47.17% )
4 (7.55% )
Number O
f Men (%
)
Age In Years
AGE O F M ALE PARTNERS n=53
URBAN/ RURAL DISTRIBUTION OF URBAN/ RURAL DISTRIBUTION OF THE COUPLESTHE COUPLES
Rural, 28
(52.83% )
Urban, 25
(47.17% )
n=53
0
5
10
15
20
25
30
Class I Class II Class III Class IV Class V
0
30(56.60% )
12(22.65% ) 11(20.75% )
0
Number O
f Couples (%
)
Socio-Econom ic Classes (M odified K uppuswam y Scale)
SOCIO-ECONOMIC STATUS OF THE SOCIO-ECONOMIC STATUS OF THE COUPLESCOUPLES
n=53
DURATION OF INFERTILITY OF DURATION OF INFERTILITY OF THE COUPLESTHE COUPLES
0
5
10
15
20
25
30
1-3 yrs 4-5 yrs 6-10 yrs 11-15 yrs >15 yrs
7 (13.21% )
27 (50.94% )
9(16.98% ) 7 (13.21% )3 (5.66% )
Number O
f Couples (%
)
Duration O f Infertility
n=53
Prim ary Infertility,
33 (62.26% )
12
2 13
2
Secondary Infertility,
20(37.74% )
Spontaneous abortion
Induced abortion
Ectopic pregnancy
Pregnancy continued up to 28-37 weeks
Pregnancy continued >37 weeks
n= 53
PAST OBSTETRIC HISTORY OF THE PAST OBSTETRIC HISTORY OF THE WOMENWOMEN
Com bined factors14
(26.42% )
Unexplained12
(22.64% )
17
2432
Single factor27
(50.94% )
M ale subfertility
Endom etriosis
PCOS
Chronic anovulation (without PCOS)Unilateral tubal block
CAUSE OF INFERTILITY OF THE CAUSE OF INFERTILITY OF THE COUPLESCOUPLES
n=53
Seminal Parameters
Number Of Male
Partners(n = 53)
Percentage (%)
Mean ± SD
Sperm density (per ml)
≥20 x 106 36 67.9238.04 ± 24.34
≥10 x 106
<20 x 106 10 18.87≥5 x 106 <10 x 106 7 13.21
Normal sperm
morphology
≥15% 36 67.9222.19 ± 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
INITIAL SEMINAL PARAMETERS OF INITIAL SEMINAL PARAMETERS OF MALE PARTNERSMALE PARTNERS
0
10
20
30
40
50
60
70
80
90
≥20 ≥10 <20 ≥5 <10
81(56.64% )
42 (29.37% )
21(14.69% )
Number O
f IUI Cycles (%
)
IM SC In m illion/m l
n= 143
INSEMINATING MOTILE SPERM INSEMINATING MOTILE SPERM COUNT (IMSC)COUNT (IMSC)
OVARIAN RESPONSE TO THE DRUGS OVARIAN RESPONSE TO THE DRUGS USED FOR OVULATION-INDUCTIONUSED FOR OVULATION-INDUCTION
18 (12.59% )
46 (32.17% )
25 (17.48% )
32 (22.38% )
19 (13.29% )
3(2.10% )
Num ber And Size O f The Follicles
One, 16-18 m m One, >18 m mTwo, 16-18 m mTwo, >18 m mThree, 16-18 m mThree, >18 m m
n=143
13 (09.09% )
83 (58.04% )
47 (32.87% )
0 10 20 30 40 50 60 70 80 90
<7 m m
7-9 m m
>9 m m
Num ber O f IUI Cycles
Endometr
ial Thickness
Endom etrial Thickness (O n The Day O f hCG Injection)
n=143
ENDOMETRIAL THICKNESS ENDOMETRIAL THICKNESS
OUTCOMES OF IUI IN TERMS OF OUTCOMES OF IUI IN TERMS OF PREGNANCYPREGNANCY
Total Number of Couples
Total Number of IUI Cycles
Number Of Pregnancy After IUI
Reported Live Birth
53 143 14 8Pregnancy 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%
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND NUMBER OF IUI PREGNANCY AND NUMBER OF IUI
CYCLESCYCLES
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND AGE OF THE PREGNANCY AND AGE OF THE
WOMENWOMEN
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND DURATION OF PREGNANCY AND DURATION OF
INFERTILITYINFERTILITY
RELATIONSHIP BETWEEN PREGNANCY RELATIONSHIP BETWEEN PREGNANCY AND TYPE OF INFERTILITYAND TYPE OF INFERTILITY
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND INITIAL SEMINAL PREGNANCY AND INITIAL SEMINAL
PARAMETERSPARAMETERS
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND INITIAL SEMINAL PREGNANCY AND INITIAL SEMINAL
PARAMETERS (Contd.)PARAMETERS (Contd.)
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND INITIAL SEMINAL PREGNANCY AND INITIAL SEMINAL
PARAMETERS (Contd.)PARAMETERS (Contd.)
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND OVARIAN PREGNANCY AND OVARIAN
RESPONSERESPONSE
RELATIONSHIP BETWEEN RELATIONSHIP BETWEEN PREGNANCY AND ENDOMETRIAL PREGNANCY AND ENDOMETRIAL
THICKNESSTHICKNESS
Why Six Cycles?Studies showed-
most women conceive after most women conceive after 4-6 cycles 4-6 cycles of IUIof IUIcycle fecundability declines by cycle fecundability declines by ½ to ½ to 22//33 thereafter 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
1. Ragni G et al. Fertil Steril. 1999;72(4):619-222. Khalil MR et al.; Acta Obstet Gynaecol Scand. 2001 Jan, 80(1): 74-813. National Institute of Clinical Excellence. Fertility: Clinical
guidelines. No 11. London: Abba Litho Ltd. UK, 2004
• 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%
1. Miller D et al. Urology 2002;60:4972. Van der W LA et al. J Asst Reprod Gen 1998;15:359-643. 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%
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 yearsIn our study-
Maximum success- 20-25 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 26-30 years (33.33%)
DETERMINANTS OF IUI OUTCOME (Contd.)
Duration of InfertilityMathieu 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
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%)
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- 10-20 x 106/ml 10-15% sperms had normal morphology >50% sperms had normal motility
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
1. Abdalla HI et al. Hum Reprod 1994;9:363-52. Basil S. Ultrasound Obstet Gynecol 2001;18:258-63. Seddigheh E et al. Fertil Steril 2006;88:432-37
Number of Follicles
Pregnancy ratesIberico et al (2004)
Our Study
One 6.2% 5.55-8.70%Two 12.9% 8.00-12.50%Three 30.0% 10.53-33.33%
COMPLICATIONS OF IUIImportant complications- 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
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