Transcript Document

WHEN TO MOVE FROM IUI TO IVF?
Dr(Brig) R K Sharma VSM
DIRECTOR HOD
IRMIC
IUI
Effective , non invasive, relatively
simple & inexpensive method of
treatment.
Can be provided easily in simple
setups.
INDICATIONS OF IUI
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Mild to moderate Endometriosis
Unexplained infertility
Anovulatory infertility
Cervical infertility
Immunological abnormalities
Mild degrees of male factor infertility
Non-consummation of marriage due to –
ED/vaginismus
PRE REQUISITES FOR IUI
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Atleast one patent functional tube
Evidence of ovulation
Adequate sperm count
Responsive endometrium
Approximate chance for success getting pregnant with one month
of various treatments
Female age under 35, 2 years of trying to conceive
Type of Treatment
Total Motile Sperm Count (in millions)
Less than
1
1-5
5-10
10-20
Intercourse
IUI
Clomid plus IUI
0.2%
0.4%
0.5%
1%
2%
2%
4%
2.5% 5%
2.5% 3%
5%
7%
7%
9%
FSH plus IUI
0.5%
2.5% 6%
9%
In Vitro Fertilization - IVF
with ICSI*
40%
40%
40% 40%
*IVF results depend upon the clinic
> 20
12%
40%
THE IMPACT OF THE TOTAL MOTILE
SPERM COUNT
Pregnant group
Non pregnant group
Total motile sperm count
38.7 x 106
28.6 x 106
Significance was reached when the total
motile sperm count exceeded 5 x 106.
The impact of the total motile sperm count on the success of intrauterine insemination with husband's
spermatozoa. Huang HY, et al. J Assist Reprod Genet 13: 1, 56-63, Jan, 1996
THE IMPACT OF THE TOTAL
MOTILE SPERM COUNT
An average total motile sperm count of 10x106
may be a useful threshold value for decisions
about treating a couple with IUI or IVF.
Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine
insemination and in vitro fertilization. Van Voorhis BJ, et al. Fertil Steril 2001 Apr;75(4):661-8
SPERM QUALITY NECESSARY FOR
SUCCESSFUL INTRAUTERINE
INSEMINATION
• Initial sperm motility  30%
• The total motile sperm count  5 X 106.
• When initial values are lower, IUI has little
chance of success
Comparison of the sperm quality necessary for successful intrauterine insemination with World
Health Organization threshold values for normal sperm. Dickey RP, et al. Fertil Steril 1999
Apr;71(4):684-9
IMPACT OF SPERM
MORPHOLOGY
Patients with more than 60% normal
sperm morphology (NSM) had higher
pregnancy rate than those with less than
60% NSM (24.3% vs. 7.7%, P=0.0052).
Intrauterine insemination: pregnancy rate and its associated factors in a university
hospital in Iran Zahra Rezaie, et al. Middle East Fertility Society Journal,Vol. 11, No. 1,
2006, pp.59-63
ADVANCED SEMEN ANALYSIS HIGHLY PREDICTIVE OF IUI SUCCESS
• The number of motile normal sperm
available for insemination
• 24-hour survival rate.
Advanced semen analysis: a simple screening test to predict intrauterine insemination
success. Branigan EF, et al. Fertil Steril 1999 Mar;71(3):547-51
SPERM-PREPARATION
TECHNIQUES- IUI RESULTS
•Abnormal semen analyses.
–Density gradient is superior to the swim-up technique in
improving AR, HOS and nuclear maturity rates.
• Normal semen analyses.
–When only nuclear maturity rate is taken into account, the swimup technique seems to be sufficient for selecting spermatozoa.
Sperm-preparation techniques for men with normal and abnormal semen analysis.- A comparison.
Erel CT, et al. J Reprod Med 2000 Nov;45(11):917-22
IMPACT OF NUMBER OF IUI
PER CYCLE
Pregnancy rate significantly higher with
increasing the number of IUI per cycles, being
24.1% and 11.8% in two IUI per cycles and one
IUI per cycle respectively
Intrauterine insemination: pregnancy rate and its associated factors in a university
hospital in Iran Zahra Rezaie, et al. Middle East Fertility Society Journal,Vol. 11, No. 1,
2006, pp.59-63
Single iui better cochrene 2009
IMPACT OF INFERTILITY
DURATION ON IUI RESULTS
Pregnancy rate decreased with increasing
infertility duration.
Zhao Y, et al. Impact of semen characteristics on the success of intrauterine insemination. J Assist
Reprod Genet. 2004 May; 21(5): 143-8
Age and number of eggs
Faddy et al., 1992
2005 CDC IVF Report –
Impact of advancing female age on IVF success
IMPACT OF IUI ATTEMPTS
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Most pregnancies in the first 3 attempts
IUI treatment is not usually recommended for more than a
maximum of 4-6 cycles
If the reason for infertility is anovulation, it may be more
reasonable to try several more cycles (6-9 cycles total).
Plosker SM, et al. Predicting and optimizing success in an intra-uterine insemination programme.
Hum Reprod. 1994 Nov; 9(11): 2014-21
CC / OVARIAN CANCER
• Incidence of ovarian cancer in women
taking CC was about three times greater
than the expected incidence for the general
population.
Rossing MA, et al. Ovarian tumours in a cohort of
infertile women. N Engl J Med 1994;331:771–
776
CC / OVARIAN CANCER
• No significant difference between the observed
incidence of ovarian cancer in women treated with
CC and the expected incidence in the general
population
Venn A, Watson L, Bruinsma F, et al. Risk of cancer after use of fertility drugs
with in-vitro fertilisation. Lancet 1999;354:1586–1590.
Parazzini F, Negri E, La Vecchia C, et al. Treatment for infertility and risk of
invasive epithelial ovarian cancer. Hum Reprod 1997;12:2159–2161.
Mosgaard BJ, Lidegaard O, Kjaer SK, et al. Infertility, fertility drugs, and
invasive ovarian cancer: a case-control study. Fertil Steril 1997;67:1005–
1012.
Shushan A, Paltiel O, Iscovich J, et al. Human menopausal gonadotrophin and
the risk of epithelial ovarian cancer. Fertil Steril 1996;65:13–18.
CAUTION
Prolonged use of clomiphene citrate
may be associated with an increased
risk of a borderline or invasive
ovarian tumour.
SPECIAL SITUATIONS
•Evidence of impending OHSS during IUI
•Add antagonist and convert to IVF
RISK FACTORS FOR POOR OUTCOME WITH IUI
• Advanced female age
• Poor postwash sperm motility
• History of corrective pelvic surgery
Poor postwash sperm motility in combination with either
of these other two risk factors resulted in no successful
pregnancies
The effect of patient and semen characteristics on live birth
rates following intrauterine insemination : A Retrospective
study HENDIN B. N.et al. Journal of assisted reproduction and
genetics ; 2000, vol. 17, no5, pp. 245-252
Sperm DNA fragmentation
decreases the pregnancy rate in
an assisted reproductive
technique
Mehdi Benchaib et al.Reproduction Vol.18, No.5 pp. 1023±1028, 2003
Patient may have normal
semenology and have high DFI
(DNA fragmentation index) or a
very poor count and motility ,yet
betterDFI.
Many cases of unexplained
infertility who are unable to
conceive by IUI,IVF/ICSI can do
better after treatment of causative
factors of abnormal DFI or by
testicular extraction of sperm and
ICSI
NOW REASONS FOR THE
CLINICIAN TO MOVE FROM
IUI TO IVF
WHEN MORE THAN 05 IUI CASE
MONTH
400 CASES
EFFECTIVE
OF
IVF/YEAR-COST
WHEN YOU WANT TO BE
DIFFERENT
When you get information that your
competitor is planning to open an
IVF Centre
When you are able to fish an
embryologist from others pond
IMPORTANT
Each centre should define its policy which takes
into account
•Diagnostic laboratory techniques available,
•Selection of the SPERM PREP technique
•Pregnany rates achieved
•Sensibility of the treated population
•Health care characteristics
DECIDE -WHEN TO MOVE FROM IUI TO IVF?
THANK YOU
HAPPY ANNIVERSARY
ART CENTRE AIIMS
WHERE MOTHERS ARE BORN