Author Name: Dr. Pooja Kumari || Mentor Name: Dr. Reema Sircar on April 27, 2020

Intrauterine insemination is an ART technique in treatment of infertility in which the washed and concentrated sperms are placed inside the uterus of a woman with the help of a catheter. It is used in variety of causes of infertility like mild male infertility, unexplained infertility, mild endometriosis, cervical factor infertility, ejaculatory disorders, vaginismus etc.
The success rate of IUI even in the best of centres worldwide varies from 5 to 20% only. The reasons for such low rates can be many. The success of IUI depends on various factors like:
• Patient selection
• Female age
• Indication for IUI
• Type of medicines used for ovarian stimulation
• Kind of monitoring
• Semen preparation Technique and
• Technique of IUI itself.

1) Female age-

The most important determinant is the age of the female. Many studies have shown a sharp decrease in the success rate of IUI beyond female age of 35. It can be due to poor ovarian reserve, oocyte quality and reproductive ageing. Increasing male age may also be associated with decline in semen volume, sperm motility and sperm morphology. This may have additive adverse effect when female age is also more than 35 years. So ideally it should be recommended to the couple <35 years age and duration of infertility <8-10 years.

2) Indication of IUI –

this is a major determinant for success in IUI. Among various indications, success rate has been higher among PCOS or ovulatory dysfunction and mild male infertility. Endometriosis has poor success rate and is one of the most difficult condition to treat successfully. The best results were obtained in cervical indications- mucus hostility or stenosis.

A. Indications for Treatment: Male Factor Infertility
In cases of male factor infertility, best results are obtained when total motile sperm count in insemination specimen exceeds a threshold of approximately 10 million and 14 % or more of sperm morphology (strict criteria WHO standard iii) Higher counts do not further increase success rate. And IUI is seldom successful if fewer than 1 million count is present. Studies shows a direct relationship between the number of spermatozoa (in the initial analysis or in the catheter) and the pregnancy rate.

B. Indications for Treatment: Unexplained Infertility
Ovarian stimulation followed by IUI is an effective treatment for couples in which infertility is
unexplained. In practice, IUI along with ovarian stimulation is seen to be generally superior to
timed intercourse planned in stimulated cycles with higher pregnancy rate.

3. Type of stimulation:

There are various methods to stimulate the ovary in IUI, with the aim to increase the number of oocytes(eggs) available for fertilization and increase the chance of conception.
The commonly used drugs to stimulate ovaries are clomiphene and letrozole. Clomiphene was usually the first one to be used. Nowadays, many prefer letrozole over clomiphene. In addition to these oral medicines, certain injectable hormones can also be used. The fertility specialist may also choose to combine the oral drugs with the injectables or the latter can be used alone, depending upon the case. In general, addition of injectables, wherever required, were seen to increase the
chances of IUI success.

4. Cycle monitoring and timing of HCG trigger:

Monitoring the cycle with transvaginal sonography improves the chances of success. It also helps to decide the timing of trigger. Optimal size of the follicle, status of the uterine lining called endometrium, can be better visualized. It is a good practice for doctor doing the IUI to do monitoring scans themselves for a better understanding of the progression of the stimulated cycle. Likewise, not monitoring the cycle and not doing the scans yourself may contribute to sub optimal follow up of the cycle and hence its failure.

5. Timing of insemination:

It is very important factor and insemination should ideally be done after 35-36 hours of trigger. If
possible, rupture of eggs should be seen before IUI.

6.Semen Collection

Sample should be collected by aseptic technique in a sterilized jar. Ideally, semen collection should
be done in premises of hospital. Semen preparation should be done in proper andrology lab. Sperm
preparation lab should be in same setup where IUI is to be done. This is a very important factor
which often determines the success of IUI. Roughly, the time period between sample collection
and its processing should not exceed half an hour and time between collection and insemination
should be less than 90 minutes. Often, it is not practically possible to strictly adhere to the time
limit especially in high volume labs and this then becomes the limiting factor.

7. Semen preparation:

IUI must be done with the washed sample of semen. Using unwashed or non-processed semen may leads to pain abdomen, infection and even fainting attacks. The purpose of sperm preparation is to concentrate the normal motile sperms with intact functional and genetic properties including normal morphology and minimal DNA damage and to separate unwanted seminal plasma with anti-fertilization contents. Different types of sperm washing techniques may be applied though none has been shown to be superior than the other. In general, labs doing IUI alone are using ‘swim-up’ technique and labs which handle both IUI and IVF are using ‘density gradient’ technique. This has more to do with the ease and is not a hard and fast role.

8. Factors related to the IUI procedure itself:

Special precautions should be taken while doing IUI to improve the pregnancy rate eg couple should be treated for any kind of infections, IUI may be done under usg guidance especially in difficult cases. Simple steps like optimal bladder filling can make a considerable difference in technique. By all means, long traumatic procedure should be avoided. Washed sample to be placed slowly inside the uterus. Minimal handling of the cervix should be encouraged. Cervical mucus may be cleaned. The use of soft or hard catheter does not make a difference in pregnancy rate as long as the procedure is atraumatic and smooth. Extended bed rest immediately after the procedure is no longer recommended. Luteal phase needs to be supported with progesterones in case gonadotropins were used for ovarian stimulation.

Success of IUI depends upon multiple factors. Case selection and good technique are very important. However, despite all the precautions, IUI has a low success rate of 5- 20% only even in ideal case scenario at best of centres. Couple should be well counselled about this right in the beginning to avoid unrealistic expectations later. They should also be counselled that a failed IUI is not the end and there are other

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