Stress Urinary Incontinence (SUI) : Dr Sharda Jain
How to make IUI cost effective
1. How to make IUI cost effective
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar
Dr. Abhishek Singh Parihar
2. How to make IUI cost effective
• Proper patient selection
• Necessary investigations and optimum monitoring.
• Choosing proper drugs for controlled ovarian stimulation
and IUI (COH/IUI).
• Proper sperm washing methods.
• One insemination per cycle.
• The optimum number of cycle of COH/IUI to be decided
and referral for advanced procedure like IVF at the
correct time.
4. Tubal Patency
1. Screening for tubal occlusion : Before
starting IUI, screening for tubal
occlusion should be performed.
2. At least One tube should be patent
5. IUI & Male factor
• Severe male infertility < 5 million TMSC
• Moderate Male infertility <10 million TMSC
• Mild Male infertility 10 – 15 million TMSC
Review of literature of IUI
• None of the patients with triple sperm defects conceived.
• No pregnancy was observed when the sperm concentration
before swim – up < 5 million
6. IUI & Male Factor
• Sperm count >15 million gives good results.
• Sperm Count Less Than 10 Million : Medical
therapy with antioxidant in idiopathic male
infertility improves count - Repeat Semen after
2 months.
If still <10 million/cmm or if already treated
elsewhere, then go for IVF - ICSI.
• Sperm count between 10 to 15 million- Offer
IUI if not done earlier
7. Good Result : - Unexplained I
: - Cervical Factor I
: - Anovulatory I
: - Donor IUI
Poor Results :- Severe male infertility
Tubal factor/
Pelvic adhesions
Severe endometriosis
Indications for IUI
8. • Couple with Unexplained Fertility problems
should be offered stimulated IUI.
• Couples with Male Factor sub fertility problems
should be offered unstimulated IUI if women is
ovulating.
• Couple with Cervical Mucus Hostility should
be offered unstimulated IUI.
• Donor Insemination IUI can also can use
unstimulated cycles.
Indications for
Stimulated & Unstimulated IUI:
9. Total Number of IUI cycles
• Couple with male factor fertility problems should
be offered up to six IUI cycles.
• Couple with unexplained fertility problems
should be offered minimum three & maximum up
to six IUI cycles if < than 35 yrs.
10. Monitoring in (Un)/Stimulated IUI:
• Patients undergoing Controlled Ovarian
Stimulation plus IUI should be monitored
by transvaginal Ultrasonography.
• Patients undergoing Unstimulated IUI can
be monitored by LH urinary measurements
(done twice a day) after 10th day of cycle.
11. Choosing the Right Drug for prevention
of ovarian hyper stimulation & IUI
• COHS reported five – fold increase in
pregnancy rate in comparison to natural cycle.
• Although less effective than gonadotriphins,CC
were more cost effective in IUI therapy.
• In Anovulation, development of single follicle by
CC should increase the chance of pregnancy .
• In Ovulatory women - Aim of CC is to develop
multiple follicles & thus increase the chance of
12. Dose of Gonadotropins
in stimulated IUI
• The dose of gonadotropins in the first cycle
of stimulated IUI should be 75 IU per day.
• The dose of gonadotropins should be raised
if ovarian stimulation does not result in two
or three follicles larger than 16 mm.
• If the dose of gonadotropins is raised to
achieve multi follicular growth, it should be
done with 37.5 IU per day per cycle.
13. IUI should be kept a simple
procedure
• No role of Down regulation with Gnrh
Agonist
• There is no role of Growth Hormones
in IUI cycles
14. IUI & Gnrh Antagonist
In nearly 20-25% cases of Gonadotrophin
cycles, there is premature LH surge
Addition of Gnrh antagonist at the follicle
size of 14mm helps such patients with
pregnancy
15. Timing of IUI
• IUI should be performed 38 to 42 hours
after administration of hCG trigger.
• IUI should be performed 20 to 30 hours
after detection of spontaneous LH
surge.
16. Timing of hCG administration
in stimulated IUI
• Patients undergoing stimulated IUI with
gonadotropins should be administered hCG
when the dominant follicle diameter reaches
18mm.
• Patients undergoing stimulated IUI with
(Clomiphene) should be administered hCG
when the dominant follicular diameter
reaches 20 – 24 mm
17. Dose of HCG in stimulated IUI
should be 5000 IU
18. Number of Inseminations in a cycle
Single IUI insemination is less expensive
& with similar pregnancy rates as two
insemination in a single cycle.
19. • Proper Labeling of semen specimen
• Prolong Abstinence to be avoided (<3 or > 10 days)
• Viscous Semen - Collect in bottle with media
• Semen preparation - swim – up , density gradient
Individualize as One size does not fit all
• High quality of Consumables & media
IUI Lab secret
Semen Preparation in doctor’s office or very close to doctor
20. • Full Bladder
• Cx mucus aspiration
• TARGET TIME - 90 minutes from collection to
insemination
• Load – when ready
• No free space at catheter tip
• Rest 10 mints
• Emergency tray to be kept ready
Easy IUIis the Key
Details of IUI techniques
21. Cancellation criteria
in stimulated IUI to avoid OHSS
• An IUI cycle should be canceled if ovarian
ultrasound reveal five of more follicles >=12
mm or three or more follicles >= 16 mm.
• Advice to withhold from unprotected sexual
intercourse should be given if ovarian
ultrasound reveal five or more follicles >=12
mm or three or more follicles >=16 mm
23. •Unexplained infertility
•Mild endometriosis
•Mild male factor infertility
In patients with
X Do not offer IUI
Advice them to try to conceive for a
total of 2 years before offering IVF
(NICE Gridlines 2013)
24. DGF Recommendations in
• Unexplained infertility
• Mild endometriosis
• Mild male factor infertility
A minimum of 3 cycles and maximum of 6 IUI cycle are
recommended in above conditions
IF AGE <35 YRS
• Trial of IUI - Maximum 3 cycles with
COH Can be given before offering IVF
IF > 35 YRS
• Offer IVF directly
25. GENERAL
• Couples who are unable to
or find it difficult to have
normal intercourse
because of
physical
psychosexual
problem
• eg. man is HIV positive
• Same sex relationship
SPECIFIC CONDITIONS
Intrauterine insemination
Unstimulated IUI
Insemination is to be timed around
ovulation
26. Women who are ovulating regularly & have
patent tubes should have minimum of 6
cycles of insemination without ovarian
stimulation to reduce the risk of multiple
pregnancies (2004,amended 2013)
Artificial insemination for
Ejaculatory disturbances
Stimulated cycle Unstimulated cycle
27. If the man is HIV positive ……
The risk of transmission to the female partner is
negligible if
•The man is compliant with highly active
antiretroviral therapy (HAART)
•Plasma viral load is less than 50 copies / ml
for more than 6 months
Unprotected intercourse at the time of ovulation
Sperm washing does not further reduce the risk
of infection
28. If the man is HIV positive…….
But not compliant
offer sperm washing
29. HIV & IUI
In counseling - it should be made clear that
HIV transmission can not be completely
prevented.
31. PREGNANCY RATES PER CYCLE WITH
VARIOUS TREATMENT OPTIONS
In unexplained infertility
Method Pregnancy Rate (%)
Intercourse (Timed) 4 (Follicle Monitoring)
IUI 6 ---do----
CC 6 ---do----
CC+IUI 8
FSH / HMG 7.7
CC / Gondotrophins /IUI 9-12
Gondotrophins /IUI 17 – 20 %
Gondotrophins +Gnrh antagonist +
IUI
25%
In vitro fertilization 20 to maximum 40 (seeing the latest US data 2014)
32. • Over 50 % of women under 35 years will
conceive within 6 cycles of IUI
• Of those who do not conceive within 6 cycles
of IUI about half will do so in next 6 cycles of
IUI provided the patient is young
Chances of conception in IUI
in women under 40 years
Cumulative pregnancy rate is
over 75 %
No Pregnancy is invariably seen after 40 years
33. Success with IUI
in relation to sperms
• IUI using fresh sperms is associated with
higher conception rates than frozen thawed
sperms .
• Intrauterine insemination is associated
with higher conception rates than intracervical
insemination even with frozen sperms .
• Donor sperm should always be IUI as it
improves the pregnancy rates
34. Why Intra uterine Insemination Fails
• Poor semen preparation
• Poor selection of patients
• Improper egg pick-up by fimbria due to
peritubal adhesions
• Prevalence of empty follicle syndrome or
poor Oocyte quality.
35. Other Known causes are
-Cause of infertility least pregnancy rate in male
infertility & severe endometriosis
- Age >35 yrs in women & > 40 yrs in men
- Duration of infertility > 5 yrs
-Number of IUI cycles > 3
-sperm parameters TMSC < 5 million.
- Not using controlled ovarian hyperstimulations
Why Intra uterine Insemination Fails
36. IVF is more Cost- Effective
• Women above 35 with Unexplained
infertility
• Elderly women with Mild Male
Factor (cohlen et al)
• Women with Advanced Endometriosis.
37. When considering IVF as
a treatment option…
Discuss the risks and benefits of IVF
INFORM THE COUPLE …
• One full cycle of IVF consists of
↓
• 1 episode of Ovarian Stimulation
with or without ICSI
• Transfer of fresh or frozen embryo(s)
(new 2013)
38. Women less than 40 years
who have not concieved after
* 2 yrs of unprotected intercourse or
* 6 cycles of stimulated IUI
Offer full 3 cycles of IVF with /
without ICSI
(new 2013)
39. In women aged 40 – 42 years
Who have not conceived after
* 2 yrs of unprotected intercourse
*2 cycles of IUI
offer IVF/ ICSI with donor eggs
40. Refer directly to an IVF specialist
Where investigations show there is no
chance of pregnancy with expectant
management , irrespective of the age
Eg tubal block
IVF is the only effective
treatment in these patients
(new 2013)
41. Summary
How to make IUI cost effective ??
Or DGF’s IUI Guidelines 2014
• Minimum investigations
• If gonadotrophins needed
- Low dose - Type of Gn, U- FSH, HMG
- Clear Cancellation protocol of cycle
• USG monitoring E2 rarely
• HCG of ovulation trigger or Spontaneous rupture
• Use of LH kit in unstimulated cycles
• One insemination in the cycle
• Minimum post wash semen concentration to be about 5 -10 million
• Proper sperm washing method which is cheaper
• Optimum number of cycle
• Referral to IVF unit at proper time
42. ADDRESS
35 , Defence Enclave, Opp. Preet
Vihar Petrol Pump, Metro pillar no.
88, Vikas Marg , Delhi – 110092
CONTACT US
011-22414049, 42401339
WEBSITE :
www.lifecarecentre.in
www.drshardajain.com
www.lifecareivf.com
E-MAIL ID
Sharda.lifecare@gmail.com
Lifecarecentre21@gmail.com
info@lifecareivf.com
