INTRAUTERINE INSEMINATION Protocol

1. INTRAUTERINE INSEMINATION
Protocol
Aboubakr Elnashar
Benha university hospital, Egypt

2. INDICATIONS
A. Male:
I. Ejaculatory failure:
anatomical (hypospadias), neurological (spinal cord
injury), retrograde ejaculation (multiple sclerosis)
II. Male subfertility:
hypospermia, oligospermia, asthenozoospermia,
teratozospermia (OAT syndrome).
Severe male infertility (Count<10 million/ml, normal
morphology <10% or motility <20) is not candidate
for IUI but ICSI.
IVF with ICSI is more cost effective than IUI when
the mean total motile sperm count is <10 million
(Van Voorhis et al, 2001)
ABOUBAKR ELNASHAR

3. B. Female:
I. Cervical factor:
cervical mucous hostility, poor cervical mucous
II. Endometriosis:
mild & moderate
III. Ovulatory dysfunction
IV. Combined non-tubal infertility factors
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4. C. Both:
I. Immunological:
male antisperm antibodies, female antisperm
antibodies (cervical, serum)
II. Unexplained infertility:
Superovulation with IUI is the first choice treatment
for:
Mild male factor infertility,
Unexplained infertility or
Minimal to mild endometriosis
ABOUBAKR ELNASHAR

5. WORKUP PRIOR TO IUI
For male:
Semen analysis
For female:
Hysterosalpingogram
Baseline ultrasound:
To exclude ovarian cysts or endometrial polyps
D2 or 3 FSH & LH:
Elevated LH & FSH may predict poor follicular
response.
Raised LH/FSH: PCOS: excessive response.
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6. STEPS
I. Ovarian stimulation
In unexplained infertility & male factor infertility:
CC 100 mg from D2 to 6 & FSH 75 IU daily from
D5
FSH 75 IU daily from D3.
When the leading follicle is >18 mm: 5000 –1000 IU
of HCG to achieve final follicular maturation &
rupture.
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7. II. Monitoring of follicular growth & endometrial
development
Baseline U/S:
Serial U/S: From D8 of stimulation
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8. III. Timing of insemination:
HCG (5000-10000 IU) or rLH (Ovatrell)
when the leading follicle >18mm: ovulation should
be expected to occur 34 to 36 h after the injection.
HCG should be withheld if
1. Number of mature follicles > 4
2. Number of follicles > 12 mm > 8
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9. Single insemination:
34 to 36 H after the hCG injection.
Double insemination
If low sperm count or male factor infertility.
1st: 12 H from the hCG administration
2nd: 34 H from the hCG administration.
Coitus
On the day of hCG administration.
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10. IV. Sperm preparation:
Swim-up technique:
simple and the cheap
Density gradient centrifugation (DGC):
Most of studies show no difference in the IUI
outcomes with the use of either technique, although
a borderline benefit of DGC over swim-up technique
was shown by a meta-analysis by Duran et al.
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11. Collection of semen:
1. By masturbation into a sterile container after 3-5
days of sexual abstinence.
2. The container should be warm {minimize the risk
of cold shock}
3. Addition of culture media to the pots before
semen collection {improve motility} if there has been
previous marked viscosity
4. In cases of impaired liquefaction, increased
viscosity & inferior semen quality: obtain split
ejaculate (the first 3 ejaculatory emissions are
collected separately).
{In 90%: the highest sperm concentration, better motility, lower viscosity
& lower PG concentration are present in the first split fraction. In 10%:
semen quality is superior in the second fraction}.
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12. V. Insemination
Precautions:
1. Aseptic technique to avoid infection
2. Gentle technique to avoid trauma of the
endometrium {may lead to cramping & bleeding
which may adversely affect the survival of
spermatozoa}
The use of tenaculum during IUI may not affect the
pregnancy outcome.
(Park, 2010)
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13. Technique:
1. Lithotomy position
2. The cervix is exposed with bivalve speculum &
rinsed with saline
3. The catheter is firmly connected to the cone of
1cc tuberculin syringe, the plunger is withdrawn
slightly, & the sperm suspension is then aspirated
from the test tube into the catheter without any air
bubbles.
If catheter passage through the cervix is difficult:
grasp the cervix with tenaculum to straighten the
utero-cervical angle by gentle traction
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14. 4. The catheter tip is advanced close to the fundus
& inseminate is gently expelled.
Leave the catheter in place for short time & then
withdraw it slowly to avoid suction effect & prevent
reflux
5. Supine position for 15 min.
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15. NUMBER OF CYCLES
IUI with or without COH should be offered for 4 to 6
cycles.
{Little benefit if any beyond the sixth cycle}.
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16. ABOUBAKR ELNASHAR