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Intrauterine Insemination
Ghumman Sindhu Surveen
CHAPTER ONE:
Indications and Patient Selection for IUI
INSEMINATION WITH HUSBAND'S FRESH SPERM
Male Factor
Retrograde Ejaculation
Cause
Diagnosis
Goal of Management
Treatment
Impotence or Ejaculatory Dysfunction
Treatment
Hypospadias
Hypospermia
Non Liquefying or Highly Viscous Semen
Subnormal Semen Parameters
HIV Infection
FEMALE FACTOR
Cervical Factor
Ovulatory Dysfunction
Endometriosis
FACTORS COMMON TO BOTH MALE AND FEMALE
Immunological Infertility
Causes
Unexplained Infertility
Rationale of Treatment
Insemination with Husband's Frozen Semen
INSEMINATION WITH DONOR SPERMS
CHAPTER TWO:
Semen Analysis—The Practical Aspect
SAMPLE COLLECTION AND DELIVERY
Factors Affecting Collection
EVALUATION OF FRESH SEMEN SAMPLE
PHYSICAL PARAMETERS
Coagulation
Liquefaction
Appearance
Odour
Volume
Cause of low volume:
Viscosity
Causes of Increased Viscosity
pH
INITIAL MICROSCOPIC EXAMINATION
Presence and Motility of Sperms
Agglutination and aggregation
Other Cells and Debris
Absent Sperms on Initial Examination
SPERM CONCENTRATION
Method of Assessment of Sperm Concentration
Neubauer's Hemocytometer
Makler Chamber
CASA
SPERM MOTILITY
Forward Progression
CASA
SPERM MORPHOLOGY
I. WHO Criterion for Sperm Morphology
Head
Midpiece
Tail
II. Krugers Strict Criterion
Head
Midpiece
Tail
Abnormal:
Method of Measurement
CELLULAR ELEMENTS OTHER THAN SPERMATOZOA
Leucocytes
Immature Germ Cells
TESTS FOR SPERM MEMBRANE INTEGRITY
Sperm Viability by Dye Exclusion
Importance
Hypo-Osmotic Swelling Test
SPERM LONGEVITY TEST
SPERM MEMBRANE BINDING, CAPACITATION, AND PENETRATION
Hemizona Assay
Method
Hemizona Assay Index
Drawback
Hamster Egg—Human Sperm Penetration Assay (SPA)
Method
Factors Affecting Assay
Optimized Sperm Penetration Assay
Significance
ACROSOME DETECTION AND REACTION
Triple Stain Technique
Fluorescence Techniques
BIOCHEMICAL MEASUREMENT OF SPERM FUNCTION
Acrosin Measurement
Adenosine Triphosphate Measurement
Creatinine Phosphokinase Assay
DNA Determination
Reactive Oxygen Species
Others
MUCUS PENETRATION CAPACITY
Method of Collection of Cervical Mucus
Storage and Preservation
Precautions
Evaluation of Cervical Mucus
pH
Significance
Interaction between Sperm and Cervical Mucus
I. In vivo Test—Postcoital Test
II. In vitro Tests
Slide Test
Method
Capillary Tube Test
Migration Distance
Penetration Density
Migration Reduction
Precautions
ANTISPERM ANTIBODIES (ASA)
Mixed Antiglobulin Reaction Test
Immunobead Test (IBT)
1. Direct Test
2. Indirect Test
Method
Clinical Significance of Positive Test (Fig. 2.10)
Advantage of Immunobead Test Over MAR
Sperm Macrogglutination
Sperm Immobilizing Antibody
CHAPTER THREE:
Computer Assisted Semen Analysis—CASA
CHAPTER FOUR:
Setup of IUI Laboratory
REGISTRATION AND ACCREDITATION
PROCEDURES DONE IN IUI LABS
CONSTRUCTION
Space
Location
Shelves
Walls and Floors
Power
Water
Air
Waste Management
Contamination
Privacy
EQUIPMENT AND SUPPLIES
Centrifuge
Microscope
Incubator
Laminar Flow Hood
Liquid Nitrogen (LN2)
Sperm Counting Chambers (Mackler's/Cryocell)
Miscellaneous
Disposables
Instruments for Insemination Room
MEDIA
RECORDS
PERSONAL
CHAPTER FIVE:
Controlled Ovarian Stimulation and IUI
CLOMIPHENE CITRATE
Side Effects and Risks
TAMOXIFEN
LETROZOLE
GONADOTROPINS
Choice of Dosage
Protocols
Monitoring
Recombinant FSH
Advantages of Recombinant FSH
Disadvantage
Results
Problems
Recombinant LH
Induction of Ovulation by hCG or LH
GnRH AGONISTS AND ANTAGONISTS IN IUI
GnRH AGONIST (GnRH-A)
Use of GnRH Agonist in COH Protocols
Protocols for Administration
Long Protocol
Advantages of Long Protocol
Disadvantage
Short Protocol (Fig. 5.6)
Advantages
Disadvantage
Ultra Short Protocol (Fig. 5.7)
Use of GnRH Agonist in Depot Preparation (Ultralong Protocol)
Advantage
Disadvantage
Disadvantage of Agonists in IUI
Advantages of Agonists
Complications
Results of GnRH agonists in IUI cycles
Specific Indication for GnRH Agonists Use in IUI Cycles
GnRH ANTAGONISTS
Mechanism of Action
Contraindications
Protocols
Role of GnRH Antagonist in Scheduling IUI Avoiding Weekends
Advantages of GnRH Antagonists over GnRH-agonist in IUI
COH and IUI vs IVF
CHAPTER SIX:
Sperm Preparation Techniques for IUI
STEPS OF SPERM PREPARATION
Semen Collection
Problems in Collection
Semen Analysis
Techniques
Swim-up Technique with CO2 Based Media (Fig. 6.5) (See CD-ROM)
Disadvantage
Advantage
Double Density Gradient Technique by Medicult Suprasperm (Fig. 6.6) (See CD-ROM)
Disadvantage
Advantage
Other Techniques Which have been used for Sperm preparation
Comparison of Various Methods
Problem Samples
Troubleshooting
CHAPTER SEVEN:
Techniques of Artificial Insemination
INTRAUTERINE INSEMINATION
Time of Insemination
Basal Body Temperature
Cervical Mucus Assessment
Ultrasonography
Detection of LH Surge
Management of LH Monitoring in Donor Insemination
Relevance of Determining Concentration of LH in Donor IUI
Protocol for Donor Insemination with LH Level Estimation
Accuracy of LH Surge Detection
Injection hCG to Time Ovulation
Number of Inseminations
Transportation of Loaded Sample and Time Interval between Loading and Insemination
Temperature Change
pH Changes
Infection
Choice of Insemination Cannula
Diameter
Rigidity
Length
Shape
Catheter Design
Soft Artificial Insemination Catheters
Firm Artificial Insemination Catheters
Is the Type of Catheter as Important in IUI as in IVF for a Favorable Outcome?
Semen Analysis
Quantity of Prepared Fluid to be Injected
Speed of Injection
Loading of Sperm Suspension
Precautions
Position of Patient for IUI
Procedure for Intrauterine Insemination
Instruments
Method
Post Insemination Record
Method of Insemination with the Makler Insemination Device
Method
Post Insemination Instructions
DIFFICULT SITUATIONS IN IUI
Acutely Anteverted Uterus
Acutely Retroverted Uterus
Stenosed Cervix
Precautions Taken During Dilatation of Cervix
Abnormal Cervical Canal
Apprehensive Patient
ROLE OF SONOGRAPHIC GUIDANCE IN DIFFICULT SITUATIONS
INSEMINATION IN SPECIAL SITUATIONS
Intrauterine Insemination in Retrograde Ejaculation
Paracervical Technique of Insemination with Oligospermic Cup
Intracervical Insemination (ICI)
Intrafollicular Insemination (IFI)
Transvaginal Intrafallopian Insemination
Fallopian Sperm Perfusion
Direct Intraperitoneal Injection
Advantages
Disadvantages
CHAPTER EIGHT:
Determinants of Success and Optimizing Success of an IUI Program
FEMALE FACTOR
Age
Cause of Infertility in Female Partner
Cervical Factor and Immunological Infertility
Type of Infertility
Controlled Ovarian Stimulation (COS)
I. Stimulation Protocol
II. Cause of Infertility
Number of Preovulatory Follicles
Endometrium
Indicators of Vascular Compliance in Ovarian, Uterine and Spiral Arteries
Identifying Time of Ovulation
MALE FACTOR
Age of Male Partner
Collection of Semen
Semen Parameters
Motile Sperm Count
Severe Oligospermia
Sperm Morphology
Other Parameters
Type of Male Infertility
Effect of Sperm Processing Methods
Cryopreservation of Sperms
Modulation of Sperm Motility with Motility Enhancing Agents
Action
Effect of Motility Enhancing Agents on Success of IUI
COMMON FACTORS
Duration of Infertility
Number of IUI Cycles
How Many IUI's per Cycle should be Performed
Insemination Technique
Type of Catheter
MULTIPLE PREGNANCY
PROTOCOL FOR OPTIMIZING SUCCESS
CHAPTER NINE:
After Insemination—The Luteal Phase
PATHOPHYSIOLOGIC MECHANISM
Why Luteal Support is Needed in Controlled Ovarian Stimulation (COS) with IUI?
DIAGNOSIS OF LUTEAL PHASE INADEQUACY
TREATMENT OF LUTEAL PHASE DEFECT
I. Increasing Progesterone Levels
Progesterone Supplementation
Natural Progesterone
Oral Administration
Vaginal Administration
Advantages of Vaginal Administration
Intramuscular Administration
Dydrogesterone
The Dual Role of Dydrogesterone — Maintenance of Pregnancy
Synthetic Progestational Agents
Results
Monitoring
Human Chorionic Gonadotropin (hCG)
Estrogen Supplementation in Luteal Phase
Duration of Luteal Support
II. Improving Folliculogenesis
Clomiphene Citrate
Human Menopausal Gonadotropins
CHAPTER TEN:
Donor IUI Psychological and Legal Aspects
INDICATION FOR DONOR INSEMINATION
Consent
PROGRAM FOR SCREENING AND TESTING OF PROSPECTIVE DONORS
Who are Sperm Donors?
Screen for Infections
HIV Testing
Other Tests
Minimal Semen Parameters Recommended for Donors (ASRM Guidelines)5
Collection of Semen
EVALUATION OF THE FEMALE RECIPIENT
Medical and Reproductive History
Screening Tests
Genetic Screening
Documentation and Timing of Ovulation
Evaluation of Possible Tubal or Peritoneal Abnormalities
STEPS OF IUI
TECHNIQUE OF IUI
COMPLICATIONS OF IUI
FACTORS AFFECTING SUCCESS RATES OF DONOR INSEMINATION
Cryopreservation Technology and its Limitations—Effect on Success of Donor IUI
Advantages of Cryopreserved Sperms
Disadvantages
Reasons for Poor Pregnancy Rates
Why is Timing more Important in Donor IUI Programmes?
Number of Inseminations per Cycle
Precisely Timed Insemination
Optimal Sperm Quality
Steps to Increase Motile Sperm Population Delivered During Donor Insemination
Fertility Potential of Donors
Effective Means of Identifying High Productive Donors
Donor Recipient Matching
Fertility Potential of Recipient
Number of Cycles
Controlled Ovarian Stimulation
Evaluating Commercial Suppliers
OUTCOME OF DONOR INSEMINATION
Success Rate
Abortions
Neonate
PSYCHOLOGICAL ISSUES AND COUNSELLING
LEGAL ASPECTS and ICMR GUIDELINES FOR DONOR INSEMINATION
Responsibilities of the Clinic
Confidentiality
Maintain Records
Rights of Child
AID for Single Woman
Known Donor
Obtain Sperm from Appropriate Bank
DNA Finger Printing
Mixing of Semen
Consent
Death of Donor
Legal Issue in Marriage
APPENDIX I
APPENDIX II
Appendix III
CHAPTER ELEVEN:
Complications of IUI
COMPLICATION DUE TO PROCEDURE
Infection
Prevention
Bleeding
Cause
Trauma
Pain
Non-infective Salpingitis
Allergic Reaction
Precautions
Antisperm Antibody
Vasomotor Symptoms
COMPLICATIONS DUE TO CONTROLLED OVARIAN HYPERSTIMULATION
OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
Incidence of OHSS
Classification
Pathophysiology of OHSS
Clinical Features
Fatal Complications
Prevention
Investigation and Monitoring of OHSS Patient
Treatment
Mild
Grade I
Grade II
Reassess: Reassessment is required if:
Indication of Hospitalization
Aim
Treatment of Critical OHSS
MULTIPLE PREGNANCY
OVARIAN CANCER AND OVULATION INDUCTION
OTHER COMPLICATIONS
Abortion
Ectopic Pregnancy
Accidental Wrong Samples
CHAPTER TWELVE:
Sperm Cryopreservation
PRINCIPLES OF CRYOBIOLOGY
Changes in Volume of Sperms when Exposed to Cryoprotectants
INDICATIONS OF SEMEN CRYOPRESERVATION
Common Indications for Autologous Semen Banking
Indications for Donor Semen Banking
OUTLINE OF CRYOPROTECTANTS
Biochemical and Physical Aspects of Sperm Cryopreservation
ESSENTIALS OF FREEZE THAW CYCLE
Specimen Glycerolization
Packaging of Semen after Addition of Cryopreservative
1. Plastic Straws
2. Plastic Cryovials
3. Glass Vials
4. Syringes
Cooling and Warming Rates
Freezing
Storage
Thawing
ASSESSMENT OF POST-THAW FERTILITY
STEP BY STEP METHODOLOGY IN SEMEN FREEZING
Disposables
Equipment
Chemicals/Media
CRYOPRESERVATION—STEP BY STEP
The Techniques for Semen Cryofreezing Using Liquid Nitrogen Vapour Cooling
Technique Using Controlled Rate Freezing
Method
Freezing
Straws
Cryovials
Thawing
CROSS INFECTION IN THE SEMEN BANKS
SECURITY AND MAINTAINENCE
THE FUTURE OF SEMEN CRYOPRESERVATION
Cryopreservation of Epididymal Sperms
Cryopreservation of Testicular Sperms
Cryopreservation of Sperm in Empty Human Zona Shell
Vitrification Technique for Ultrarapid Freezing
Appendix A
Sperm Freezing Medium
Medicult
Sperm Freezing Medium (SFM)
Composition
COOK MEDICAL (K-SISC)
Composition
Human Serum Albumin
GLYCEROL EGG-YOLK CITRATE (GEYC)
Composition
CHAPTER THIRTEEN:
Male Infertility: The Andrologist's Perspective
CHAPTER FOURTEEN:
Ultrasonography and IUI
THE OVARIES
CERVIX
THE UTERUS
Endometrium
Myometrium
Septate Uterus
Fibroid
Polyps
Adenomyosis
FALLOPIAN TUBES
COLOUR DOPPLER IMAGING IN OVARIAN PHYSIOLOGY AND CYCLIC CHANGES
COLOUR DOPPLER IMAGING IN UTERINE PHSIOLOGY
Uterine Artery
Endometrium
Endometrial Morphology
Endometrial Vascularity
Endometrial Thickness
Endometrial Volume on 3 D Ultrasound
Peristaltic Contractions of Subendometrial Myometrium
Ultrasonographic Scoring of Uterine Receptivity
Comparison of 3-D and 2-D Ultrasonography for Assessment of Endometrial Receptivity
CHAPTER FIFTEEN:
Semen Banking—Ethical and Legal Aspects
LEGAL ISSUES OF IUI IN MARRIAGE
Adultery in Case of ART
Consummation of Marriage in Case of AIH
RIGHTS OF A CHILD BORN BY AID
Legitimacy
Right to Information
Divorce
SEMEN BANKS
Who can Set It?
Who can be a Donor?
Age of Donors
Requirements for a Sperm Donor
DNA Fingerprinting
Donor Rights
Donor Anonymity
Is Anonymity of the Donor Justified?
Records
Who can Use the Semen?
Cryopreservation
How Long should Gametes be Stored?
Charges of Semen Banking
Consanguity and Limiting Donor
Payment of Donors
Death of Donor
Collection of Sperm from a Dying Person
Posthumous AIH through a Sperm Bank
INDEX
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