BY

Prof. Dr. Mohamed A. Emam

Mansoura Faculty of Medicine Ob. & Gyn. Dept.
Mansoura integrated Fertility Center (MIFC)
 Intrauterine Inseminations (IUI)

• Traditional:
• (widely used 0.2-0.5 ml washed sperm intraut).
• Modified ( Fallopian tube sperm perfusion):-
• Twice as effective (Trout and Kemmenn 1999).
• 4ml of prepared semen over 4min (1ml each min).
• Insemination performed before ovulation (Oocyte
flushed out of the tube).
 History of IUI

As a technique:
• Direct intrauterine insemination (neat semen)
- Disadvantage:
- PG cramps Abondoned
(Stone et al,
- Infection. 1986)
• Split ejaculate
• The advances in IVF, ET. reviving IUI.
 Reviving the interest in IUI

Advances in:-
• Progress in semen processing and sperm isolation methods.
+
• Improved ovarian stimulation protocols (developed primarily to
meet IVF requirements) →↓ ↓side effects.
IUI progress is due to advances in
IVF, ET.
 Advantages of IUI

• Bypass (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
 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)
 IUI Steps

• Selection + counseling
• Protocol (spontaneous or stimulated cycle)
• Folliculometry&Endometrial thickness.
• Timing of insemination.
• Semen preparation.
• Procedure:
 Selection and counselling
• Complete work up of infertility:
(Semenogram- midluteal progestrone - HSG + laparoscopy)
• Indications.
• Adequate counseling
• Confidence of husband.
• Religious
• Cost
• Failure & success
• Complications.
 Success of IUI
The review of literature over the past 15 years
• wide range of variation
•0-26% pregnancy / cycle in different indications
•MIFIC (22%).
Take home baby

•Controversy No evidence- based infertility data.

Factors affecting success of
IUI
Couple:
(age,duration of infertility,cause of
infertility,BMI).
Therapies:
• Semen processing technique.
• Protocol of COH.
• Timing of insemination.
 Timed intercourse versus IUI
Probability of conception

• Natural cycles (IUI ↑)

• COH cycles (IUI ↑ ↑ ↑)
( Cochrane database 2000)
Spontaneous cycle protocol
• Cervical factor.
• Sexual dysfunction.
-D 10-11 monitor every 2 days.
-Follicle 18-20 mm hcg 10,000 u.
-Insemination 36 h after hcg.
-Pregnancy test (hcg in serum 2w after
insemination).
Ovarian Stimulation Protocol
• Rationale for use COH
-↑↑Number of oocytes available
-↑Steroid production ↑( chance of implantation )

• Protocols commonly used

• 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.
 Ov. Stim. Protocol con..

• TVS monitoring of follicular growth and endometrial

development
-Baseline TVS (day 2 -3 of Menst.)
-Serial TVS (day 7-8 of stimulation)
-Follicle 18-20 mm hcg 10,000 u.
-Insemination 36 h after hcg.
-Pregnancy test (hcg in serum 2w after insemination).
 Timing of insemination

• Rationale:
viable sperms should be present at the time of ovulation.
• Detection of ovulation
• serum or urinary LH
• TVS (leading follicle > 18mm) HCG 10.000 IU
• Insemination:
• one versus two (24 h & 48 h) from HCG
• or TVS after 36 h :
1- Ovulate IUI
2- Not Ovulate IUI at once
IUI 24H later
 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.
 Procedure of IUI
• Prior to insemination.
• Cusco’s speculum.
• Catheter (types)
• During insemination:
• Utero cervical angle
• Catheter insertion.
• Insemination (catheter withdrawal)
• After insemination
• Rest ?!
• Luteal phase support
 Where IUI is done?

• Ideally in a clinic with IVF facilities

(all services under one floor)
-OHSS
-IVF choice.
-Freezing extra embryos.
 Where IUI is done?
IUI in the office setting

• Benefits:
1. OB/Gyn extend their fertility care beyond
the basic workup to provision of first-line
therapies.
2. Maintaining the existing parent-OB/Gyn
relationship for a longer period without
referral.
Pre-Requisites for office IUI
1. Organization the practice to be extended in
the week ends or holidays.
2. TVS probe ± Ovulation prediction kits.
3. Office semen processing or RSP service
(Remote Semen preparation).
4. Familiarity about the optimal time for
referral the case to an infertility specialist.
 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.
 Recent advances: SIFT
(Sperm Intrafallopian transfer)

• Speically designed catheters (Jansen-

Anderson Catheter Sets)

• The processed sperm can be injected into

the tubes laparoscopically OR guided
by ultrasound without anaesthesia or
surgrey.
 Conclusion
While many gynecologists offer IUI office procedure,
many of them are not specialized enough to provide
a comprehensive service. This means that:
1. Patients need to run from gynecologist to ultrasound
scan center to the lab.
2. Fragmented care because of poor coordination.
SO
An ideal clinic is that which offers all the services under
one roof.
 T HANK YOU
Prof. DR. MOHAMMAD EMAM
Prof. OB& GYN, Mansoura Faculty of Medicine
Member of Mansoura Integrated Fertility Center (MIFC)
Telefax 0020502319922 & 0020502312299
Email. mae335@hotmail.com