Past , Present & Future of IUI

Introduction :—   IUI is a very old  as well as  established method to treat infertility. The aim of this presentation  ‘Past , Present & Future of IUI’  is to make people  aware about future of  IUI.  In future what should be the aim and how it can be targeted  will be emphasized.  Past, present & future of IUI  is having a history of   two century.  Certainly future of IUI  will be unlimited.  Technology of IUI has improved a lot but still there is a long distance to travel  to get more  success in IUI.

Overuse of IVF / ICSI is another aspect. Our discussion ’Past , Present & Future of IUI’ will not focus  on any aspect of other modality of infertility management.  Our aim will be to discuss  the measures or changes required  to improve productivity of  IUI.  Which will ,hopefully,  improve the success rate and efficacy of IUI in future.

IUI  — Intra uterine Insemination,   IVF — In vitro fertilisation,  ICSI — Intracytoplasmic sperm injection,  ET – Embryo transfer.

Past  of  IUI :–

  • According to available data first IUI reported in 18th century by an Scottish surgeon John Hunter. He performed and effective procedure by using husband sperm.
  • 1884, was the year,  first time a live birth is in record by using donor sperm by  William Pankhurst from Philadelphia.
  • In second half of 20th century IUI  used  in cattle & pigs  as very preferred  method to maintain  pedigree  &  improve yield.
  • Direct Intra-Peritoneal Insemination (DIP) was tried  in 1980s.  It was concluded in multiple study that  direct intra-peritoneal insemination (DIP) does not offer  better pregnancy rate than IUI.

Present  of  IUI :–

In present  scenario  IUI is a common & popular  procedure  among all ART (assisted reproductive technologies,  i.e.  – IVF-ET, ICSI) procedure.

  • The popularity of IUI is because of —
    • Simple to perform
    • Cost effective / Expensive infrastructure not required
    • Non invasive technique
    • IUI is possible even with limited resource.
    • Very low risk for complication
    • Less stressful for patient & staff
    • IUI with ovarian stimulation  is in many countries first-line fertility treatment for couples with unexplained and mild male infertility.
  • One obvious indication for IUI is use of donor semen.    When  donor  semen  is used in IUI, it is  called  IUI-D.  IUI-D is  performed  with following indication –
    • No sperm in semen (Azoospermia)
    • Abnormal sperm (asthenozoospermia  or  asthenoteratozoospermia)
    • When man is carrier of genetic mutation
    • In case of inherited disorder. e.g. – Huntington’s disease or hemophilia
    • High risk of disease transmission, e.g. – HIV, Hepatitis, etc.
    • Severe Rhesus incompatibility  of the mother
    • Single women , who want to have a baby
    • Female Homosexual couple,  willing  to have a baby
  • There are also known indication for IUI with husband    When husband sperm is used for IUI, it is called IUI-H.   IUI-H   is  indicated in following  condition –
    • IVF is not affordable due to financial barrier.
    • Sexual disorder. e.g. —  erectile dysfunction, ejaculatory failure, vaginismus,  hypospadius, etc.
    • Premature ejaculation.
    • Cervical factor infertility
    • Cervical scar due to some prior operation of cervix, not allowing the sperm to cross cervix.
    • Early stage of endometriosis
    • Psycho-sexual problem, where intercourse is not possible.
    • When patient need special method of treatment, (e.g – sperm washing in case of HIV infected male partner).

Future  of IUI :–

  In Future the  IUI must  be upgraded with the aim  to  —-

  • Get maximum success rate.
  • Minimum complication rate.
  • Incorporation of new easy and success oriented method

Maximum success rate  — Success  rate of any technology depends on frequent positive up-gradation  and continuous  follow up. Which ultimately prove the superiority or inferiority of new technology.   Usually up-gradation is based on  past and present experience of particular technology.

The success rate of IUI can be increased by minimizing or replacing the factors which stimulate the uterus to reject the sperm or components of culture media used in IUI.

  1. In usual case sperms are not treated as foreign body by uterine cavity. But in some case anti sperm antibody can be detected.  Even the level of anti sperm antibody can be high enough to cause infertility.
  2. Proteins / component  of serum from other individual is capable of stimulating an immune response to produce antibody.

Reducing the antigenic activity of sperm and replacing the serum component of other individual  by non antigenic salt appear  an effective measure to improve future of IUI.

Minimum Complication rate :-   Complication , like infection, disease transmission, particularly  transmission of unidentified & emerging  viruses  can be abolished by  not using  human, animal or    avian  protein or blood product.

Incorporation of new method :-   Introduction of Intra Uterine Tubo-Peritoneal Insemination (IUTPI)  is a promising approach. Where washed sperm is flushed in uterine cavity & fallopian tube.  Followed by clamping of  cervix to prevent  leakage of sperm  to the vagina.  In future this may be a preferred  method of IUI.

Discussion  –  One obvious measure is  to replace the use of H.S.A. (Human Serum Albumin)  or any  complex protein for IUI.  H.S.A.  is a potential  source to transmit many infections.  Moreover H.S.A. is a  complex molecule. Its function  is  still not very clear.  Certainly it improve the motility of sperm but because of its unknown & doubtful structure, it may affect the end result adversely  also.  Replacement of H.S.A. or any  human, animal or avian protein by some defined molecule is a proper way.   New technology should be always under trial.

Conclusion  –  To sum up, the intrauterine insemination is cost effective and efficacious procedure to treat infertility.  Reduction in antigenic activity of sperm is a good approach. If we think about Future of IUI.   Replacement of H.S.A. by more simple and chemically defined substance is a demand for  future of IUI.  New method should  be always under trial.

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