Download Document

OVULATION INDUCTION
&
INTRAUTERINE
INSEMINATION
By
S. Nasseri
ANOVULATORY DISORDERS
The clinical approach to ovulation induction requires an understanding of
the causes of anovulation. The World Health Organization (WHO) classified
different categories of anovulation into three categories:
●WHO class1: Hypogonadotropic hypogonadal anovulation (hypothalamic
amenorrhea [HA])
●WHO class2: Normogonadotropic normoestrogenic anovulation (almost all
women in this category have polycystic ovary syndrome [PCOS]), when
using the Rotterdam criteria for the diagnosis of PCOS
●WHO class3: Hypergonadotropic hypoestrogenic anovulation (primary
ovarian insufficiency [POI; premature ovarian failure])
However, most experts have moved away from this terminology and assign
women to one of the four most common ovulatory disorders:
hypogonadotropic hypogonadism (HA), PCOS, POI, or hyperprolactinemia.
The use of serum anti-müllerian hormone (AMH) concentrations may help
to further define various patient categories
Anti-Mullerian Hormone
• AMH is expressed by the small (<8 mm) preantral and small antral
follicles.
• Serum concentrations (ELISA) reflect the number of the primordial
follicles & the size of P.F pool
• It is the best biochemical marker of ovarian function.
• Low levels correlate with reduced ovarian reserve and less than
three follicles.
• High levels correlate with a vigorous response to ovarian
stimulation and a higher risk of OHSS.
• AMH is also a predictor of ovulation induction success (N0 of
retrieved oocytes ) & therefore individualizing treatment protocols.
• AMH is also a predictor of IVF success.
GOALS OF OVULATION INDUCTION
The overarching goals of ovulation induction in women with
anovulatory infertility are:
●Induce monofollicular rather than multifollicular development and
subsequent ovulation and ultimately pregnancy and birth of a healthy
newborn .
●Start with the least invasive and simplest treatment option
subsequent options should depend upon ovarian response (ovulation
and number of follicles) .
●Maximize the rate of singleton pregnancies, minimize multiple
gestation rates.
●Minimize the risk of ovarian hyperstimulation syndrome (OHSS) in
women undergoing gonadotropin therapy, particularly those with
polycystic ovary syndrome (PCOS), who are at higher risk.
GENERAL PRINCIPLES
●The method of ovulation induction selected by the clinician should be
based upon the underlying cause of anovulation and the efficacy,
costs, risks, and potential complications associated with each method
as they apply to the individual woman.
●Women with ovulatory disorders should undergo conventional
ovulation induction strategies before considering assisted reproductive
techniques, because success rates are good, and if monitored by an
experienced clinician, complication rates are low
●Induction of ovulation should be differentiated from stimulation of
multiple follicle development in ovulatory women (usually referred to
as controlled ovarian hyperstimulation), as is done with assisted
conception techniques.
●PCOS represents a risk factor for developing OHSS following ovarian
stimulation with gonadotropins in any setting.
HYPOTHALAMIC AMENORRHEA
• Patients are hypoestrogenemic and are therefore unlikely
to respond to CC, an antiestrogen. However, because CC is
easy to administer, it may seem reasonable to give one
course of clomiphene prior to initiating pulsatile
gonadotropin-releasing hormone (GnRH) or gonadotropin
therapy.
• For those who ovulate, CC can then be continued.
• For those who do not ovulate, we suggest pulsatile GnRH
as first-line therapy in countries where it is available. If
pulsatile GnRH is unavailable, gonadotropin therapy should
be initiated, with both luteinizing hormone (LH) and folliclestimulating hormone (FSH) (these women do not respond
to FSH alone).
PCOS
• The approach to women with PCOS starts with
weight loss, if indicated, followed by ovulation
induction with either CC or letrozole
depending upon the patient’s body mass
index (BMI).
• Gonadotropins
• Metformin
• Ovarian Diathermy
PRIMARY OVARIAN FAILURE
• All ovulation induction strategies for women
with primary ovarian insufficiency (POI) are
unsuccessful and we suggest against their use.
• Women with POI should be offered the
option of in vitro fertilization with donor
oocytes.
HYPERPROLACTINEMIA
• The treatment of choice for anovulatory
women with hyperprolactinemia is dopamine
agonists.
ORAL AGENTS
•
•
•
•
Clomiphene citrate
Aromatase Inhibitors
Metformin
Dopamine agonists
CLOMIPHENE CITRATE
• Clomiphene, like tamoxifen and raloxifene, belongs to the
category of compounds known as selective estrogen
receptor modulators (SERMs). These drugs are competitive
inhibitors of estrogen binding to estrogen receptors and
have mixed agonist and antagonist activity, depending upon
the target tissue.
• CC has been the most widely used agent for ovulation
induction for over 40 years.
• It is most effective in women with polycystic ovary
syndrome (PCOS). While they could be used for ovulation
induction, tamoxifen and raloxifene appear to be less
effective than clomiphene so are not typically used for this
purpose.
SITES OF ACTION
• Primary site of action: hypothalamus
• Pituitary (direct effect):  gonadotropin release
• Ovaries (direct effect): in the absence of estrogen
 estrogen agonist FSH stimulation on LH
receptors in granulosa cells
• Uterus-Cervix-Vagina antiestrogenic effect
Clinical Outcome of Normogonadotrophic
Anovulatory Women Treated with Clomiphene
Dose of clomiphene
(mg)
Ovulation rate
(%)
Pregnancy rate
(%)
50
100
150
200
250
52.1
21.9
12.3
6.9
4.9
52.8
20.7
9.8
8.8
6.2
• 60 to 85 percent of anovulatory women,
typically with PCOS, ovulate in response to CC.
• Of those who ovulate, 30 to 40 percent
conceive.
• Predictors of pregnancy with CC are:
younger age
low BMI
low FAI
Oligomenorrhea rather than amenorrhea
COMPLICATIONS
•
•
•
•
•
•
•
•
•
•
•
•
•
Vasomotor flushes (10%)
Abdominal distension, bloating, pain or soreness (5.5%)
Breast discomfort (2%)
Nausea & vomiting (2.2%)
Visual symptoms (1.5%)  blurring vision, scotoma, abnormal
perception
Headache (1.3%)
Dryness or loss of hair (0.3%)
Significant ovarian enlargement (5%) ( mild OHSS)
Severe OHSS is rare ( < 1% )
Abortion rates & teratogenicity
Incidence of multiple follicular recruitments = 35- 60%
Multiple gestation ( twin = 5-10% Triplet = 0. 3% )
Ectopic pregnancy  probably not increased
TREATMENT OF CLOMIPHENE
RESISTANT PATIENTS
• A-Medical Treatment:
•
•
•
•
•
•
123456-
Extended clomiphene treatment
Dexamethasone
Pretreatment suppression (GnRH agonist- OCP)
Bromocriptine
Gonadotropins
Insulin sensitizers
• B- Surgical Treatment
METFORMIN
• Biguanide → NIDDM
• Mechanism of action:
1- inhibition of gluconeogenesis in liver
2- ↑ uptake of glucose in periphery
• Treatment for 12 weeks:
→ ↓ fasting insulin, total testosterone,
free testosterone index, BMI, waist/hip,
hirsutism, acne
• Response:
1- Obese PCOS→ 89% ovulation rate
(CC + Met) versus 12% (CC + pla)
2- Lean PCOS→↓ hyperandrogenemia
Typical regimen using metformin with or
without clomiphene in PCOS patients
•
Start metformin :
- Metformin, 500 mg/day with breakfast for 4 days
- Metformin, 500 mg /BD with breakfast and dinner for 4 days
- Metformin, 500 mg with breakfast and 1000 mg with dinner for 4 days
- Metformin, 1000 mg /BD at breakfast and dinner
•
•
If a trial of metformin alone is chosen→ single serum progesterone weekly
(it may take up to 2 months before spontaneous ovulation)
If no spontaneous ovulation when the full dose of metformin has been reached :
- Met + CC (50mg/day) → LH kits & time intercourse
- ↑ CC dosage until ovulation occurs
•
•
Continue ovulatory dosage of CC+ Metformin up to 3-6 cycles → LH kits &
time intercourse
If no response→ Review the diagnosis→ Gonadotropins or Ovarian diathermy
Laparoscopic Ovarian Drilling
•
•
•
•
Unipolar or bipolar cautery (Ovarian diathermy)
Laser
↓ LH, testosterone, DHEAS, LH/FSH
Further 73% spontaneous ovulation, 24% ovulation
with CC, 1.8% ovulation only with Gonadotropins
• Median time to conception = 10.2 months
• Cumulative pregnancy rate:
- After 12 months about 50%
- After 24 months about 80%
LETROZOLE
• It is an aromatase inhibitor.
• It blocks the conversion of testosterone and androstenedione to
estradiol and estrone, respectively.
• Letrozole reduce negative estrogenic feedback at the pituitary and
increase FSH output .
• In contrast to CC, letrozole appears to be free of the adverse effects
on endometrial and cervical mucus .
• A large randomized trial and a meta-analysis of nine trials in
anovulatory women with PCOS now suggest that letrozole therapy
results in higher live-birth and ovulation rates when compared with
clomiphene therapy. The effect appears to be most pronounced in
obese women with PCOS (BMI >30 kg/m2).
• Therefore, some experts now suggest letrozole as a first-line drug
for obese women with PCOS.
In general , from the available data there is no
convincing evidence that letrozole is
superior to clomiphene and therefore the
cost should be taken into account when
using anti-estrogens
DOPAMINE AGONISTS
• Bromocriptine, the first dopamine agonist drug to prove effective in
the treatment of hyperprolactinemia, remains in widespread use.
• Drugs that bind more specifically to dopamine D2 receptors on the
lactotroph cells, such as cabergoline, are associated with fewer side
effects.
• The safety of bromocriptine with regard to teratogenesis is much
better established than that of cabergoline, so many clinicians and
patients prefer bromocriptine to attempt pregnancy, but patients
who have severe side effects from bromocriptine prefer
cabergoline.
• We suggest either bromocriptine or cabergoline for ovulation
induction, depending upon the patient’s preferences.
• Treatment should be stopped once pregnancy has been diagnosed.
GONADOTROPINS
•
•
G.T were first introduced into clinical practice in 1961
Gonadotropins extracted from the urine of postmenopausal
women (human menopausal gonadotropins [hMG]), in which the
ratio of luteinizing hormone (LH) to follicle-stimulating hormone
(FSH) bioactivity is 1:1.
• Refinement of the initially crude preparation resulted in the
availability of purified and highly purified urinary FSH (uFSH).
• Since 1996, recombinant human FSH (rhFSH, >99 percent purity)
has been available.
• Recombinant preparations are appealing due to their ease of
administration (SC rather than IM), purity, and batch-to-batch
consistency.
DIFFERENT TYPES OF
GONADOTROPIN PREPARATIONS
GONADOTROPINS
•
•
•
•
•
•
•
HMG( Pergonal) (1961)
Purified Urinary FSH (Metrodin)
Recombinant FSH (Gonal F- Puregon )(1996)
Recombinant LH (Luveris –Lutropin alfa)
rFSH + rLH ((2:1) (Pergoveris)
HCG
Recombinant HCG (Ovitrelle)
COMPARISION OF DIFFERENT G.T
PREPARATIONS
• hMG and FSH — The degree to which the type of FSH compound
employed may influence outcome of ovulation induction remains
the subject of controversy.
• HMG & uFSH: Two meta-analyses comparing the effectiveness of
daily uFSH to daily hMG for inducing ovulation in PCOS women
demonstrated no difference in pregnancy rate per treatment cycle .
However, the women given FSH were less likely to have OHSS.
• rFSH &uFSH: In a meta-analysis of randomized controlled trials
comparing rhFSH with uFSH for ovulation induction in PCOS, no
significant differences were demonstrated for the ovulation rate .
Furthermore, the ORs for pregnancy rate , miscarriage rate ,
multiple pregnancy rate , and OHSS showed no significant
difference between rhFSH and uFSH.
CANDIDATES Of GONADOTROPINS
●Women with polycystic ovary syndrome (PCOS)
who have not ovulated or conceived with weight
loss, clomiphene, or letrozole therapy .
●Hypogonadotropic anovulatory women with
hypopituitarism or women with hypothalamic
amenorrhea (HA) who do not have access to
pulsatile gonadotropin-releasing hormone
(GnRH) therapy.
WHICH GONADOTROPIN ?
• In PCOS patients FSH is better because of
elevated LH
• no differences in PR using rFSH
or uFSH
• In Hypothalamic Amenorrhea: HMG
rFSH +rLH
PROTOCOLS
• The aim of ovulation induction with gonadotropins, as with
CC, is the formation of a single dominant follicle.
• In spontaneous cycles, this is achieved at the beginning of
the cycle by a transient increase in serum FSH
concentrations above the threshold value . The
concentrations then decrease due to negative feedback,
preventing more than one follicle from undergoing
preovulatory development .
• Because ovarian sensitivity to FSH stimulation varies
among individual women, specific treatment and
monitoring protocols are needed to achieve development
of a single follicle when exogenous gonadotropin is
administered.
• Low-dose step-up protocol which is the
preferred method since 1990 in PCOS
patients.
• Step-down protocol (OHSS)
• Sequential Protocol which combines an initial
step-up followed by a step-down regimen
after leading follicle >or= 14 mm (OHSS)
Chronic low dose Step up protocol
Cycle day3
75IUFSH/day
7days
Foll<10mm
Maintain dose
Foll>10mm
7days
Maintaindose
Until foll>18mm
Foll<10mm
Increase by37.5 IU/d
Foll>10mm
7days
Foll<10mm
Increase dose 37.5IU/w
Max=225iu/d
Foll<10mm
Cancel cycle
Increasing starting dose
By37.5IU/d
Foll>10mm
Foll>10mm
hCG injection
Step down protocol
Cycle day 3
150-250IU
FSH/d/5d
Ultrasonography
(every2-3 days)
foll>9mm
Foll<9mm
Decrease 37.5
IU/day
Every 3 days
Increase 37.5IU/d
Maintain 10days
Maintain 75IU/day
Until hCG injection
foll>9mm
Foll<9mm
Cancel cycle
DOSES OF GONADOTROPINS
• In the conventional gonadotropin protocol, the
starting dose of FSH is 150 u/day. However, this
regimen is associated with a multiple PR of up to
36 percent and OHSS occurs in up to 14 percent
of treatment cycles .
• In patients with PCOS, who are at particular risk
for complications, this approach has been
abandoned in favor of a low-dose, step-up
protocol designed to allow the FSH threshold to
be reached gradually, minimizing excessive
stimulation and development of multiple follicles.
LOW – DOSE STEP- UP
• In this protocol, the initial subcutaneous or
intramuscular dose of FSH is 37.5 to 75 u/day.
• It is recommended that the dose be increased
only if, after 14 days, no response is documented
on ultrasonography and serum estradiol
monitoring.
• Increments of 37.5 u then are given at weekly
intervals up to a maximum of 225 u/day .
• The detection of an ovarian response is an
indication to continue the current dose until hCG
can be given to trigger ovulation.
LOW-DOSE STEP-DOWN
• This protocol mimics more closely the physiology of
normal cycles .
• Therapy with 150 unit FSH/day is started and
continued until a dominant follicle (>10 mm) is seen on
TVS.
• The dose is then decreased to 112.5 int. units/day
followed by a further decrease to 75 i.U/day three days
later, which is continued until hCG is administered to
induce ovulation.
• The appropriate starting dose can be determined by
using the low-dose step-up regimen for the first
treatment cycle .
MONITORING
•
•
•
•
•
The ovarian response to gonadotropin therapy is monitored using
transvaginal ultrasonography to measure follicular diameter.
The scans during the late follicular phase, usually performed every
two or three days, should be focused on identifying follicles of
intermediate size.
hCG is given as an ovulatory trigger on the day that at least one
follicle appears to be mature. The criteria for follicle maturity are a
follicle diameter of 18 mm and/or a serum estradiol concentration
of 200 pg/mL (734 pmol/L) per dominant follicle.
Ovulatory triggers : hCG ; rhCG; GnRH ago
If three or more follicles larger than 15 mm are present, stimulation
should be stopped, hCG withheld, and use of a barrier
contraceptive advised in order to prevent multiple pregnancies and
OHSS.
RESULTS WITH GONADOTROPIN
TREATMENT
•
•
•
•
•
CPR after 6 treatment cycles→ 90%
Pregnancy rate in obese PCO (40%) is less than lean PCO
Spontaneous abortion rate → about 25%
Spontaneous abortion is more frequent in obese PCO
↑Risk of EP because of multiple oocytes & high hormone
level
• Multiple pregnancy rate → 30% (triplet or more 5%)
• Ovarian Hyperstimulation Syndrome (severe ,1-2%)
• Normal incidence of congenital malformations
PREGNANCY RATES IN DIFFERENT PROTOCOLS
•
•
•
•
•
A series of 225 women with PCOS treated over a 10-year period in one center found rates of
ovulation and pregnancy of 72 percent and 45 percent, respectively, after use of the lowdose step-up protocol . Multiple folliculogenesis and ovarian hyperstimulation are less
common than that seen with the standard protocol, and pregnancy rates appear similar.
However, the results of the low-dose step-up protocol are negatively influenced by age and
obesity.
In single-center studies, the step-down protocol appeared to be accompanied by a lower
incidence of ovarian hyperstimulation and a higher incidence of monofollicular growth,
thereby reducing the risk of multiple pregnancy.
In contrast, a multicenter study reported that the step-up protocol was more efficient in
inducing monofollicular development and was associated with less ovarian hyperstimulation
Experience to-date has indicated that the major drawback of the step-down regimen is that
the initial starting dose is too high for some patients. In an effort to overcome this problem,
sequential low-dose step-up and step-down regimens have been proposed . This approach
requires further evaluation
Gonadotropin therapy after CC treatment has failed has been the "classical" approach to
ovulation induction for anovulatory infertility. Using this sequential approach, cumulative
singleton live birth rates of 71 percent (only 7 percent multiples) over 24 months have been
reported These results suggest that conventional approaches offer an effective means of
treating the majority of women with anovulatory infertility before proceeding to more
aggressive treatments such as IVF.
OHSS
• OHSS is a potentially life-threatening
complication of ovulation induction.
• Its most severe manifestations include massive
ovarian enlargement and multiple cysts,
hemoconcentration, and third-space
accumulation of fluid
• these changes may be complicated by renal
failure, hypovolemic shock, thromboembolic
episodes, acute respiratory distress syndrome,
and death.
ADJUVANT TREATMENT
• GnRH agonists (Buserelin –first used in 1984)or
antagonists( Cetrorelix – early 2000s) are
commonly used for women with ovulatory
infertility undergoing “controlled ovarian
hyperstimulation” with gonadotropins in the
setting of IVF.
• The goal is to suppress pituitary gonadotropins to
optimize control of the cycle and prevent a surge
of endogenous LH prior to full maturation of the
cohort of ovarian follicles.
SUMMARY AND RECOMMENDATIONS
The method of ovulation induction selected by
the clinician should be based upon these
factors:
• 1-underlying cause of anovulation
• 2-efficacy
• 3- costs
• 4- risks & potential complications
INTRAUTERINE INSEMINATION
• Intrauterine insemination (IUI) is a procedure
in which processed and concentrated motile
sperm are placed directly into the uterine
cavity.
Goal is to Maximize the
Chance of Fertilization
• Increase Number of Eggs
• Position Sperm Closer to
Eggs
INDICATIONS
• The impossibility of vaginal
ejaculation:
- Impotence
- Severe hypospadias,
- Retrograde ejaculation
- Cryopreservation of sperm
(cancer treatment)
• Abnormal male factor
- oligospermia
- asthenospermia
- teratospermia
• Unexplained infertility
• Cervical factor infertility
•
•
(mucus, anatomy, immunologic
factors)
Mild to moderate
endomertiosis
Chronic anovulatory cycles
Which ovarian stimulation to chose
before intra-uterine insemination?



Drug Cost; Drug availability and Patient acceptability
CC is an effective alternative for young women with
good prognosis, whereas in the remaining cases hMG
or FSH would be the preferable drug.
rFSH Vs Urinary preparations : No difference in clinical
pregnancy rate.
There is no advantage in routinely using GnRh-ago in
conjunction with gonadotrophins for ovulation
stimulation
At the moment one should use the least expensive
medication.
IUI
•
•
•
•
•
•
•
•
The minimum requirements :
patency of at least one fallopian tube
adequate number of motile sperm
absence of active cervical, intrauterine & pelvic
infection.
The pregnancy rate after IUI :
Male factors
Female factors
Technical factors
MALE FACTOR
• The minimum post-wash total motile sperm
count for IUI is controversial .
• Although pregnancies from IUI have occurred
with a post-wash total motile sperm count less
than 5 million, a count greater than 5 to 10
million is associated with higher pregnancy rates .
A count less than this warrants further evaluation
and possible treatment by a urologist.
• If samples consistently have less than 3 to 5
million motile sperm, PR will be < 1 % per cycle.
( IVF or ICSI )
SPERM COLLECTION AND
PROCESSING
• We ask men to produce a semen specimen in the
morning after two or three days of sexual
abstinence .
• The specimen is produced by masturbation,
ideally in a private room designated for this
purpose in the laboratory/office.
• The entire ejaculate is collected in a sterile cup to
minimize the risk of uterine infection from
contaminants.
• We advise avoidance of lubricants, as most are
toxic to sperm
SPERM PROCESSING
•
•
•
•
•
•
Goals
1- separate sperm in the ejaculate from prostaglandin-rich prostatic
secretions and seminal fluid, which can cause uterine cramping and,
rarely, anaphylaxis, when placed directly into the uterine cavity.
2- sperm preparation maximizes the number of motile sperm for
insemination, removes cellular debris, and concentrates the specimen.
TECHNIQUES
Swim up method and Density Gradient Centrifugation.
A systematic review of randomized trials comparing these two
techniques did not find a statistically significant difference in
pregnancy rates . However, the percentage of motile sperm is
generally higher with density gradient centrifugation than with the
swim up technique . Therefore, we prefer this method in men with
oligo- or asthenospermia.
TIMING THE INSEMINATION
• The luteinizing hormone (LH) surge can be
detected in serum 36 hours before ovulation and
in urine 24 hours before ovulation.
• The oocyte can be fertilized up to 24 hours after
ovulation;
• Sperms are most capable of fertilization up to 48
hours after entering the female genital tract.
• Timing the intrauterine insemination (IUI) is
based on these relationships. However, the
optimum time for IUI is controversial .
NUMBERS Of IUI IN ONE CYCLE
• Whether to perform one or two IUIs is also
controversial.
• In the two most recent RCTS, and a 2010
meta-analysis , the PR per cycle was similar
whether one IUI to two IUIs were performed.
• For this reason, a single IUI the day after a
urinary LH surge is recommended.
TYPES Of IUI
• Unstimulated Cycles (Natural ):
Natural cycle IUI are most appropriate for
patients with ejaculatory dysfunction,
vaginismus, or cervical factor infertility.
Once the LH surge is documented in first
morning urine, IUI is performed the next day
• Stimulated Cycles
STIMULATED CYCLES
• Clomiphene citrate : For most patients, is the
first-line approach (50 to 150 mg for 5 days),
depending on ovulatory status.
• letrozole : yields equivalent pregnancy rates as
CC in combination with IUI .
• Gonadotropins:
• older women
• younger women with diminished ovarian reserve
(or IVF )
GnRH Agonists & Antagonists
• It may improve pregnancy rates by reducing the incidence
of premature luteinization in women with some types of
ovulatory dysfunction .
• Alternatively, a GnRH antagonist can be added to the
controlled ovarian stimulation cycle when the lead follicle is
14 mm in size.
• This delays luteinization, thus allowing development of
additional follicles, which is particularly useful if only one
follicle has developed.
• Use of GnRH antagonists may also be beneficial in
preventing luteinization when IUI is delayed over a
weekend or holiday in practices with staffing restrictions
IUI PROCEDURE
Equipment
• Prepared sperm specimen
• Speculum
• 1 cc sterile syringe with blunt cannula
• Disposable polyethylene insemination catheter
Patient preparation — Proper identification of both the
patient and sperm sample in the laboratory and the clinic
is essential.
Antibiotic prophylaxis is unnecessary. Povidone iodine
should not be used to cleanse the cervix because it is
toxic to sperm.
Technique
• Aspirate the processed sperm and its
suspension media into the syringe. Ideally, the
sperm is suspended in a small volume of
media, no more than 0.5 mL, to prevent
expulsion or reflux from the cervix and uterine
contractions after it is inseminated into the
uterus.
IUI CATHETERS
• Attach the syringe to an 18 cm polyethylene
insemination catheter. Two types of catheters are
available: (1) relatively rigid single sheath
catheters (straight or with a preformed curve)
that cannot be bent and (2) double sheath
catheters with an external flexible sheath that
will maintain a curve and a very soft internal
catheter. In a 2010 meta-analysis of six
randomized trials, pregnancy and live birth rates
were the same for flexible and rigid catheters
INSERTION of CATHETER
• Without touching the end of the catheter that will enter
the sterile uterine cavity, insert the catheter through the
cervical os, through the endocervical canal, and into the
uterus to a depth of approximately 6 to 6.5 cm.
• Try not to let the catheter touch the fundus, as this will
cause cramping and, in some cases, disruption of the
endometrium and bleeding, which is toxic to embryo
development.
• If difficulty is encountered with insertion of the catheter,
use of a rigid stylet or abdominal ultrasound guidance may
be helpful.
• Inject slowly the sperm and then slowly withdraw the
catheter.
• Sperm are present in the tubes as early as five minutes
after insemination .
• Patients will rest in supine position for 10 minutes
after sperm injection.
• Although only limited data are available on whether
rest is of any value in enhancing pregnancy fertilization
rates, one randomized trial reported higher pregnancy
rates in rested patients compared with those who were
immediately mobile post-IUI
• Psychologically, patients are often reassured by a
period of rest following the procedure
Postprocedure Care
• The patient may resume her normal activities
after insemination.
• Increased wetness after the procedure is due to
loosened and watery cervical mucus, it does not
mean the sperm specimen has flowed out.
• Abdominal cramping or discomfort
• Light bleeding or spotting
• Patients may have intercourse after IUI if they
wish to do so.
• Pregnancy test : two weeks after IUI.
NUMBER OF IUI CYCLES
• Pregnancy rates are significantly lower after
the third IUI cycle, irrespective of the
ovulation induction method .( Then move on
to more aggressive treatment).
• European guidelines (Denmark, England,
Wales, France, the Netherlands) suggest three
to six IUIs, depending on the cause of
infertility .
COMPLICATIONS
• Upper genital tract infection (rare )
• OHSS (Gonadotropin cycles)
• Multiple Gestations
Thank
You for
Your
Attention