Evaluation of Role of Intrauterine Insemination (IUI) in Infertility

 “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
 ArtificialArtificial
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-ET
GIFT, ZIFT
ICSI
POST
 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)

MATERIALS AND METHODSMATERIALS AND METHODS

 STUDY AREASTUDY AREA
Deptt of Obstetrics and Gynaecology,
Eden Hospital,
Medical College and Hospital, Kolkata
 STUDYSTUDY PERIODPERIOD
1 year (1st
June, 2011- 31st
May, 2012)
 STUDY DESIGNSTUDY DESIGN
Observational 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 Criteria
1. 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 CYCLES
Number Of IUI Cycles Number Of
COUPLES
Total Number
Of CYCLES
One 10 10
Two 14 28
Three 18 54
Four 6 24
Five 3 15
Six 2 12
TOTAL 53 143

AGE DISTRIBUTION OF THE COUPLESAGE DISTRIBUTION OF THE COUPLES
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%)
NumberOfWomen(%)
Age In Years
AGE OF FEMALE PARTNERS
n=53

AGE DISTRIBUTION OF THE COUPLESAGE DISTRIBUTION OF THE COUPLES
0
5
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%)
NumberOfMen(%)
Age In Years
AGE OF MALE PARTNERS
n=53

URBAN/ RURAL DISTRIBUTION OF THEURBAN/ RURAL DISTRIBUTION OF THE
COUPLESCOUPLES
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
NumberOfCouples(%)
Socio-Economic Classes
(Modified Kuppuswamy Scale)
SOCIO-ECONOMIC STATUS OF THESOCIO-ECONOMIC STATUS OF THE
COUPLESCOUPLES
n=53

DURATION OF INFERTILITY OF THEDURATION OF INFERTILITY OF THE
COUPLESCOUPLES
0
5
10
15
20
25
30
1-3yrs 4-5yrs 6-10yrs 11-15yrs >15 yrs
7 (13.21%)
27 (50.94%)
9 (16.98%)
7 (13.21%)
3 (5.66%)
NumberOfCouples(%)
Duration Of Infertility
n=53

Primary
Infertility,
33
(62.26%)
12
2 1
3
2
Secondary
Infertility,
20
(37.74%)
Spontaneousabortion
Inducedabortion
Ectopicpregnancy
Pregnancy continuedup
to 28-37 weeks
Pregnancy continued
>37 weeks
n= 53
PAST OBSTETRIC HISTORY OF THEPAST OBSTETRIC HISTORY OF THE
WOMENWOMEN

Combined
factors
14
(26.42%)
Unexplained
12
(22.64%)
17
2
4
3
2
Single
factor
27
(50.94%)
Malesubfertility
Endometriosis
PCOS
Chronic
anovulation
(withoutPCOS)
Unilateral tubal
block
CAUSE OF INFERTILITY OF THE COUPLESCAUSE OF INFERTILITY OF THE COUPLES
n=53

Seminal Parameters
Number Of
Male Partners
(n = 53)
Percentage (%) Mean ± SD
Sperm density
(per ml)
≥20 x 106
36 67.92
38.04 ±
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 67.92
22.19 ±
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 MALEINITIAL SEMINAL PARAMETERS OF MALE
PARTNERSPARTNERS

0
10
20
30
40
50
60
70
80
90
≥20 ≥10 <20 ≥5 <10
81 (56.64%)
42 (29.37%)
21 (14.69%)
NumberOfIUICycles(%)
IMSC In million/ml
n= 143
INSEMINATING MOTILE SPERM COUNTINSEMINATING MOTILE SPERM COUNT
(IMSC)(IMSC)

OVARIAN RESPONSE TO THE DRUGS USEDOVARIAN RESPONSE TO THE DRUGS USED
FOR OVULATION-INDUCTIONFOR OVULATION-INDUCTION
18
(12.59%)
46 (32.17%)
25 (17.48%)
32 (22.38%)
19 (13.29%)
3
(2.10%)
NumberAnd Size Of The Follicles
One, 16-18 mm
One, >18 mm
Two, 16-18 mm
Two, >18 mm
Three, 16-18 mm
Three, >18 mm
n=143

13 (09.09%)
83 (58.04%)
47 (32.87%)
0 10 20 30 40 50 60 70 80 90
<7 mm
7-9 mm
>9 mm
Number Of IUI Cycles
EndometrialThickness
Endometrial Thickness(On The Day Of hCG Injection)
n=143
ENDOMETRIAL THICKNESSENDOMETRIAL THICKNESS

OUTCOMES OF IUI IN TERMS OFOUTCOMES 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 8
Pregnancy 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%

OUTCOMES OF PREGNANCY AFTER IUIOUTCOMES OF PREGNANCY AFTER IUI

RELATIONSHIP BETWEEN PREGNANCYRELATIONSHIP BETWEEN PREGNANCY
AND NUMBER OF IUI CYCLESAND NUMBER OF IUI CYCLES

AND AGE OF THE WOMENAND AGE OF THE WOMEN

AND AGE OF THE MENAND AGE OF THE MEN

AND DURATION OF INFERTILITYAND DURATION OF INFERTILITY

RELATIONSHIP BETWEEN PREGNANCY ANDRELATIONSHIP BETWEEN PREGNANCY AND
TYPE OF INFERTILITYTYPE OF INFERTILITY

AND INITIAL SEMINAL PARAMETERSAND INITIAL SEMINAL PARAMETERS

AND INITIAL SEMINAL PARAMETERSAND INITIAL SEMINAL PARAMETERS
(Contd.)(Contd.)

AND IMSCAND IMSC

AND OVARIAN RESPONSEAND OVARIAN RESPONSE

AND ENDOMETRIAL THICKNESSAND ENDOMETRIAL THICKNESS

POST-IUI COMPLICATIONSPOST-IUI COMPLICATIONS

COMPLICATIONS OF POST-IUICOMPLICATIONS OF POST-IUI
PREGNANCIESPREGNANCIES

Why Six Cycles?
 Studies showed-
most women conceive aftermost women conceive after 4-6 cycles4-6 cycles of IUIof IUI
cycle fecundability declines bycycle fecundability declines by ½ to½ to 22
//33 thereafterthereafter 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):619-22
2. Khalil MR et al.; Acta Obstet Gynaecol Scand. 2001 Jan, 80(1): 74-81
3. 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;60:497
2. Van der W LA et al. J Asst Reprod Gen 1998;15:359-64
3. 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 years
In 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%)

(Contd.)
Duration of Infertility
Mathieu 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

(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;9:363-5
2. Basil S. Ultrasound Obstet Gynecol 2001;18:258-6
3. Seddigheh E et al. Fertil Steril 2006;88:432-37
Number of
Follicles
Pregnancy rates
Iberico 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 IUI
Important 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

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