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

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

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 1-5 5-10 10-20 > 20

1
Intercourse 0.2% 1% 2% 2.5% 3%
IUI 0.4% 2% 4% 5% 7%
Clomid plus IUI 0.5% 2.5% 5% 7% 9%

FSH plus IUI 0.5% 2.5% 6% 9% 12%

In Vitro Fertilization - IVF 40% 40% 40% 40% 40%
with ICSI*

*IVF results depend upon the clinic

 THE IMPACT OF THE TOTAL MOTILE
SPERM COUNT

Total motile sperm count

Pregnant group 38.7 x 106
Non pregnant group 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 swim-
up 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

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;354:15861590.

Parazzini F, Negri E, La Vecchia C, et al. Treatment for infertility and risk of

invasive epithelial ovarian cancer. Hum Reprod 1997;12:21592161.

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;65:1318.
 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. 10231028, 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 OF IVF/YEAR-COST

EFFECTIVE
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