IUI - Intrauterine insemination - how to optimise results

Dr Aniruddha Malpani, MDMalpani Infertility Clinicwww.drmalpani.com

IUI – the basicsEggs plus sperm = baby !

1. Superovulate2. Time ovulation accurately3. Process sperm ( to improve their quality)

4. Insert sperm into the uterus with a catheter

The key to success ?What catheter you use ?How many times you do the insemination ?

( double versus single)What sperm preparation technique you use

? wash or swim up or gradient

How you superovulate ?Letrozole or clomid or HMG

Superovulate ( grow more eggs)Clomid ? Letrozole ?HMG ?FSH ?Recombinant ?How many follicles ?

Time ovulationMonitor with ultrasound scans

Follicle size and endometrial thickness and texture

Optimal follicle size ?Monitor with urinary LH stripsHCG injection for inducing ovulation

? GnRH analog for inducing ovulation

Timing of IUIBefore ovulation ?After ovulation ?How many times ?

Single ?Double

Intercourse ?

How to process the sperm ?Swim up ?Wash ?Culture medium ?With HEPES ?Add Pentoxyfylline to improve sperm

motility ?Gradient density centrifugation ?Motile sperm count ?Volume ?

Technique of IUIWhich catheter ?

Soft ? Rigid ?

Does the brand matter ?Indian ? Foreign ?

Location of catheter tip ?Fundal ?

Bed rest after IUI ?

The key to success ?What catheter you use ?How many times you do the insemination ?

( double versus single)What sperm preparation technique you use

? wash or swim up or gradient

How you superovulate ?Letrozole or clomid or HMG

The secret to IUI success ?Patient selection !

Major problem with IUIEasy to doInexpensiveEveryone wants to do itDone for all the wrong reasons

Unrealistic expectations• Patients–Eggs plus sperm = baby–Expect instant success –Get upset and frustrated–Lose confidence in doctors

Unrealistic expectations•Doctors–Do not understand limitations of IUI–Overpromise – claim success rates of 20%–Too many attempts

DangersMultiple pregnancyInfection ( poorly prepared sperm)

OHSS

Best results whenYoung patientGood spermNormal tubesNormal uterusUnexplained infertility

Poor resultsPoor sperm countOlder womenPoor ovarian reserveDamaged tubesMany previous failed IUI cycles

Real life problemsPatients run around from clinic to

scan center to labPoor documentationSperm sample – not seen by doctor

or shown to patientLong time delays after sperm is

preparedNot on a Sunday !

Take home messagesSelect patients carefullyKeep records and analyse them !

Do everything under one roofDo not do more than 4 IUIsKnow when to refer for IVF