Teknik Inseminasi Intrauterine dan Tips

mengatasi kesulitan saat Inseminasi

Hilma Putri Lubis

Division of Reproductive, Endocrinology and Infertility,

Department of Obstetrics and Gynecology, Faculty of Medicine,
Universitas Sumatera Utara, Medan, Indonesia
2022
 Outline
qTeknik inseminasi intrauterine
qTips mengatasi kesulitan saat inseminasi
qTake Home Message
 Insemination Intrauterine (IUI)

Diagnosis and Cycle

Indication Preparation

Technical
Stage

Lemmens L, et al. Human Reproduction. 2017

 Insemination Intrauterine (IUI)

1. Technique
Technical 2. Inseminated Volume
Stage
3. The type of Insemination
4. Type of catheter
5. Number of IUI
The whole process between 6. Time Intervals
semen collection and 7. Ultrasound guided IUI
insemination
8. Bedrest after IUI
Technique of IUI

Fallopian tube sperm

perfusion

Intraperitoneal
insemination

Intracervical
insemination
Conclusion. there is a significant improvement of pregnancy rates in patients with nontubal subfertility when
treated with double-sperm perfusion after controlled ovarian stimulation in comparison with single-sperm
perfusion. Double-sperm perfusion à simple, easy to perform, inexpensive, and convenient for the patients
with nontubal subfertility before adoption of other methods of assisted reproduction.

Hassan MSE. ISRN Obstetrics and Gynecology. 2011.

 200 patients, 404 stimulated cycles

Technique of IUI

IUI : 100 patients, 184 cycles

FSP : 100 patients, 220 cycles

For non-tubal sub fertility, the results indicate clear benefit for FSP (Fallopian tube sperm perfusion)
over IUI (Intrauterine insemination).

Col G.S. Shekhawat et al. Medical Journal, Armed Forces India.2012.

q From 14 RCTs, no evidence of a statistically significant difference was noted between IUI and
FSP in live birth (OR 0.94) or clinical pregnancy (OR 0.75).
q For a couple with a 13% chance of live birth using FSP, the chance when using IUI will be
between 8% and 19%; and that for a couple with a 19% chance of pregnancy using FSP, the
chance of pregnancy when using IUI will be between 10% and 20%.
q Conclusion : Currently no clear evidence suggests any differences between IUI and FSP with
respect to their effectiveness and safety for treating couples with non-tubal subfertility.

Cantineau AEP et al. Cochrane Database of Systematic Reviews. 2013.

 Intra-Uterine Insemination: Evidence Based
Guidelines for Daily Practice
Level of
Statement
Evidence
• For nontubal subfertility, the results indicate no clear
benefit for FSP over IUI 1a
• After the exclusion of studies where a foley catheter
was used, FSP resulted in a significantly higher
pregnancy rate compared to standard IUI 1a

Recommendation Grade strength

•FSP can be used as an alternative treatment option for
standard IUI in case of unexplained infertility and no foley A
catheter is used
•in case of unexplained inertility, a maximum three FSP
cycles is recommed B
Conclusion : DIPI does not offer better pregnancy chances than IUI in superovulated cycles.

Tiemessen CHJ, et al. Gynecologic and Obstetric Investigation. 1997.

Technique of IUI

From metanalysis, IUI results in higher pregnancy rates than ICI for frozen donor insemination.

Jeffrey M. Goldberg et al. fertil steril, 1999.

v There was insufficient evidence to determine whether there was a clear difference live birth rates between
IUI and ICI in natural or gonadotrophin-stimulated cycles in women who started with donor sperm treatment.
v There was insufficient evidence available for the effect of timing of IUI or ICI on live birth rates.
v Very low-quality data suggested that in gonadotrophin-stimulated cycles, IUI may be associated with a higher
clinical pregnancy rate than ICI, but also with a higher risk of multiple pregnancy rate.
 Inseminated volume

No difference in PR when the inseminated volume varied from 0.3 to 1 mL

(Do Amaral VFJ Assist Reprod Genet 2001)

The Type of Insemination

Bolus technique

Pulsatile intrauterine
insemination

Slow release
intrauterine
insemnination
 Bolus Technique

vThe entire inseminate is injected inti the uterine cavity over 1 to 3 minutes.
vBolus IUI à performed without changing the count from the swim-up portion of
the washed spermatozoa.
vDisadvantage of bolus technique à single deposition of very large number of
spermatozoa into the uterine cavity in contrast to the prolonged slow release of
small number spermazoa from the endocervix into the upper genital tract
following natural intercourse.
 Pulsatile Intrauterine Insemination

v This uses an automated pump attached to 1.0 mL syringe and deliver sperm in pulses of 15
minutes over 4 to 6 hours.
v The disadvantage of this technique à patients activity has to be restricted for 4 to 6 hours and
the patient has to be kept lying down in a supine posture.

Slow Release Intrauterine Insemination

v This technique uses an external slow release auto-syringe to inject small numbers of prepared motile
spermatozoa in a continuous slow release pattern into the uterine cavity.
v The disadvantage of this technique à patients activity has to be restricted for 4 to 6 hours and the patient
has to be kept lying down in a supine posture.
v More physiological process
v May stimulate local prostaglandin à improve the transport of spermatozoa along fallopian tube
 Type of Catheter used for insemination

vFlexible IUI catheters à Wallace catheters

vSemi-rigid IUI Catheters à Tomcat catheters

Wallace catheters
Tomcat catheters
 Type catheter of IUI

Conclusion : there was no significant difference in pregnancy rate between tomcat and wallace groups when using a standard
gentle technique that includes not touching the top of the fundus with the catheter.

Karen L. Smith et al. Journal of Assisted Reproduction and Genetics,2002.

There is no statistically significant difference between flexible and rigid catheters for
IUI.

Paul B. Miller et al. fertil steril, 2005.

 PERBANDINGAN TINGKAT KEBERHASILAN KATETER FLEKSIBEL DAN
KAKU DALAM INSEMINASI INTRA UTERI

Kehamilan
n = 30 total Nilai p
Positif Negatif
Jenis Kateter
Kaku 6 (20%) 24 (80%) 30 (100%)
Flexibel 8 (26.7%) 22 (73,3%) 30 (100%) 0,542*

Darah di Kateter
Ada 5 (14,3%) 30 (85,7%) 35 (100%) 0,050*
Tidak ada 9 (36%) 16 (64%) 25 (100%)
Refluks
Ada 2 (22,2%) 7 (77,8%) 9 (100%) 1,00**
Tidak ada 12 (23,5%) 39 (76,5%) 51 (100%)
Type catheter of IUI

Tidak ada perbedaan yang bermakna tingkat keberhasilan kehamilan yang menggunakan jenis
kateter kaku dan fleksibel.

Binarwan H, et al. 2013.

 Number of IUI per
No significant
cycle differences were observed when two inseminations per cycle were performed, compared with one
insemination.

Carmen osuna et al. fertil steril, 2004.

 TIME INTERVALS

Time interval between semen collection to processing and processing to insemination have impact to IUI.

• A higher PR was reported when semen was collected in the clinic.

• Lower PRs caused by longer time intervals, might be explained by decapacitating factors in the seminal
plasma.
• PRs were comparable when IUI was performed within 30 min or after 31–60 min of storage, but decreased
after > 60 min.
TIMING TO IUI
 73 consecutive couples, 231 IUI cycles

Technique of IUI

Utrasound-guided IUI does not produce better results than blind insemination, since the PR per
cycle is similar.
Olga Ramo´n et al. 2009.
Conclusion : The use of ultrasound during the insemination procedure increased the need for trained personnel to
perform ultrasonography and increased the cost, but added no extra benefits for patients or clinicians.

Mubarak S, et al. Clin Exp Reprod Med . 2019.

 Group A : 5 min
Group B : 10 min
Group C : 20 min

Technique of IUI

Bed rest for 10 and 20 min after intrauterine insemination has a positive effect on the pregnancy rate, but there is no statistically significance
difference between them. This study recommend bed rest for at least 10 min after intrauterineinsemination.

Yasser Ibrahim Orief et al. Middle East Fertility Society Journal. 2015
This systematic review and meta-analysis was not able to demonstrate that bed rest after
intrauterine insemination effectively increases in pregnancy rate.
For everyday practice, no specific strategy, bed rest or immediate mobilization, can be
recommended at this time.
 IUI technical aspects
— Aseptic technique to avoid genital infection

— Should be gentle and atraumatic

— Products of local tissue reaction to injury may be hostile to

spermatozoa
 Instrumen untuk IUI

Meja Ginekologi
 TEKNIK INSEMINASI
INTRAUTERINE
1. Pasien dalam keadaan full urinary bladder

2. Pasien berbaring dengan posisi dorso litotomi.

3. Spekulum cocor bebek dibilas dengan NaCl hangat.

4. Masukan spekulum ukuran standar ke dalam vagina sampai serviks tampak dengan jelas.

5. Serviks diusap dengan NaCl hangat, dilanjutkan dengan sedikit medium untuk inseminasi memakai

kapas steril.

6. Sementara pasien disiapkan, sperma yang sudah dipreparasi di laboratorium dimasukkan ke dalam

kateter Tom Cat atau Wallace.

7. Volume medium inseminasi yang akan dimasukkan ke dalam kavum uteri adalah 0,3-0.5 ml.
7. Masukkan kateter yang sudah berisi medium dan sperma melalui ostium uteri eksternum,
kanalis servikalis, sampai ke dalam kavum uteri sesuai arah yang dicatat pada waktu trial
sounding.
8. Jika ditemui kesulitan, terkadang diperlukan pemasangan tenakulum untuk menarik serviks
pada saat memasukkan kateter.
9. Prosedur inseminasi ini harus dilakukan secara perlahan dan hati-hati untuk mengurangi
cedera pada endometrium, yang dapat mengakibatkan perdarahan sehingga mengurangi
viabilitas sperma.
10. Setelah ujung kateter mencapai fundus, tarik keluar sekitar 1 cm sehingga ujung kateter
berada pada kavum uteri yang terluas. Selanjutnya, medium dan sperma disemprotkan ke
dalam kavum uteri.
11. Tarik kembali kateter perlahan-lahan keluar sambil memutarnya.
12. Pasien diminta tetap berbaring terlentang selama 15 - 30 menit pasca inseminasi.
Selanjutnya, diperbolehkan pulang dan melakukan aktivitas seperti biasa.
13. Hubungan seksual di anjurkan 24 jam pasca inseminasi.
 DOES A DIFFICULT INTRAUTERINE INSEMINATION LOWER PREGNANCY
RATES AND LIVE BIRTH RATES?

OBJECTIVE: To determine if difficulty with placement of intrauterine insemination (IUI) catheter is associated with pregnancy rates. A
difficult IUI was defined as presence of obstruction, catheter bend, cramping, and/or bleeding.

RESULTS: From a total of 2109 cycles, they found an average of 2.47±1.58 cycles per patient were performed on 703 women (mean
2.47±1.58 cycles per patient), an average age of 31.94.9 years. Any difficulty with IUI was noted in 966 procedures (47.7%). There was no
significant difference in pregnancy rates given presence or absence of any difficultly with IUI (15.1% versus 14.9% respectively; RR 1.01,
95% CI 0.83-1.24). There was no association between delivery and any difficulty with IUI (RR 0.98, 95%CI 0.75- 1.27). Individual IUI
difficulty parameters were not associated with pregnancy rates, nor were total number of difficulties.

CONCLUSION: When an IUI is ‘‘difficult’’ they hypothesized that pregnancy rates wouldbe lower. However, they were reassured to find that
having any (or all) difficulty with the IUI did not decrease the likelihood of pregnancy or delivery.

Difficult IUI

S. N. Khan et al. Fertil Steril, 2013.

 What is difficult insemination?
v Insemination: easy in 80%, difficult in 20%

v Greater resistance during catheter negotiation

v Harder catheter needed

v Cervical dilatation needed

v Blood in catheter
Why difficult Insemination ?

IO to left of EO (80%)

IO to right of EO (10%)

IO in straight line with EO (10%)

 EXT OS FLUSHED

AV, RV UTERUS
Difficult IUI: How to avoid and what to do

vKeep Cx centrally in vagina by speculum manipulation

vExternal os in transverse axis of vagina

vSlight traction on Cx with Allis’ tissue forceps: straightens

out utero-cervical angulation

vUse of forceps do not reduce pregnancy rates

 Difficult IUI: what to do next
v Ultrasound guidance
Measuring the utero-cervical angle with ultrasound
before IUI and moulding the catheter accordingly
increases clinical pregnancy.

vHysteroscopy & cervical dilatation

should be done before next IUI
 Difficult IUI: what to do next

Trial IUI enables the clinician to assess the degree of

difficulty
• assessment of depth and shape of uterus
• selection of optimal catheter type
• mappingthe easiest and least traumatic entry into uterine
cavity
• identify cervical stenosis
 Tips Mengatasi Kesulitan Inseminasi
Intrauterine

1. Tipe kateter : Rigid

2. Tenaculum
3. USG guided
4. Under anesthesi
5. Sonde/osfander
Group 1; Soft, Group 2; Firm, and Group 3; Tenaculum.

Conclusion: the use of a firm catheter or tenaculum for IUI might result in a higher CPR, but might not have a
considerable effect on the live birth rate (LBR).

Coban PG, Int J Fertil Steril. 2020.

 TAKE HOME MESSAGE

v Teknik inseminasi intrauterine meliputi tipe inseminasi intrauterine, time interval, jumlah
inseminasi, volume inseminasi, tipe kateter, USG guided dan bedrest setelah inseminasi
v Kesulitan pada saat inseminasi seperti obstruksi, cramping, perdarahan, kateter tertahan
dapat terjadi kapanpun.
v Tindakan yang dapat dilakukan untuk mengatasi kesulitan saat inseminasi yaitu
menggunakan tipe kateter inseminasi rigid, osfander/sondase, USG guided, under
anesthesi dan tenaculum.
THANK YOU