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How do you evaluate the results of IUI

letto 9736 volte | autore: Claudio Manna, ginecologo specialista in fecondazione assistita (vai al curriculum)


How do you evaluate the results of Medically Assisted Procreation (MAP)

For a couple, but also for the medical team, the only result that really counts is obtaining a healthy baby.  Nevertheless, it is not enough to furnish the results of an assisted fertility activity only in terms of children born..

Understanding and interpreting the results of medically assisted fertilisation
In effect, the global results are nothing other than average statistics that can be very different from individual probability, every birth is the result of a complete chain of events that represent as many obstacles to overcome, each stage has its own difficulties, and not all couples are the same.  Therefore, for every method of assisted fertilisation we have to evaluate the results of every stage, the global results, the success factors that determine individual probability and lastly the short and long term risks.

Intrauterine insemination (IUI)
IUI is the first in line technique used in infertility cases where the tubes are permeable and  the quality of the sperm is good. If  it is combined with a small and controlled amount of ovarian stimulation, IUI offers pregnancy percentages in the region of 13% per cycle , with a risk of multiple pregnancies of 10%, essentially of twins.  In cases of multiple pregnancies, triplets or more are very rare, less than 1 in 1000.  Since the procedure is not very difficult, IUI can be repeated for several cycles.  The statistics demonstrate that 80% pregnancies occur in within the first four  attempts and 50% of the couples who  arrive at the sixth attempt become pregnant.

The elective reason for intrauterine insemination is cervical sterility caused by  the absence of mucus or caused by hostile mucus, because the treatment surpasses the obstacle represented by the uterine neck.  The circumstances are rare and they represent a very low portion of the innumerable number of IUI currently performed. The other reasons are female infertility, male infertility or infertility without a cause. In this case, the general idea is to guarantee the presence of the maximum number of  spermatozoa possible at the precise moment of ovulation, in order to optimise the probabilities of fertilisation.  500.000 spermatozoa need to be injected into the uterus in order to have good chances of pregnancy. The results of intrauterine insemination depend on many factors: the reasons, the age of the woman, the number of attempts, the type of ovarian stimulation if effected, the tracking of the cycle and the time of insemination in relation with ovulation, the sperm preparation method, the quality of the sperm before and after the preparation, the number of spermatozoa injected and so on. Because of many variables, the results demonstrate an extreme diversity. In controlled series, for all the reasons, the percentage of pregnancies varies between 0 and 23% per cycle with an average of about 8% per cycle.

The best results are obtained in cervical sterility (15%) and in unexplainable sterility (13%). The results are less satisfying in male reasons (5%).  These figures represent  the average obtained from available literature, and have a purely indicative value because, the techniques, the stimulation and criteria that determine the reasons, especially male, are extremely diversified.  With polyovulant stimulation, the percentage of pregnancies are often in the region of 15-18% per cycle, with 20% twin pregnancies and an undetermined number of triplet pregnancies, up to 6% according to some statistics.  With monoovulant stimulation it is possible to obtain pregnancy percentages of 12% per cycle, avoiding complications : without stimulation, less than 5% of twin pregnancies, triplet pregnancies rare.  It is important to realise that almost the total number of pregnancies is reached in the first 4 – 6 cycles of IUI; in the event of failure, the advise is to carry on with treatment.  The superiority of IUI in relation with intra-cervical insemination, even in cases where there are no abnormalities of the mucus, it has been demonstrated in the model represented by donor sperm with pregnancy percentages of 19.4% after IUI against 6.7% after intra-cervical insemination.

Stimulation with IUI tries to reproduce a normal cycle, that is to obtain the emission of only one or two ovules to the end of reducing the risks of multiple pregnancies.  The global success rate  of 11% may seem modest, but does not reflect the real degree of the method: what characterises IUI in relation to the  other medically assisted techniques is that  it is simple and can easily be repeated. The probabilities increase in proportion to the number of attempts. The elective use and therefore the use in series, that is repeating IUI in successive cycles, with intervals depending on the  couples chances. The results of a series of cycles, therefore, count more than those of a single cycle.  About 30% of couples become pregnant at the end of the third IUI, and more than 40% after the fourth attempt.

These figures can be compared to those of  IVF: a series of three cycles of  IUI gives better chances of pregnancy than a cycle of IVF, with less effort and at a lower cost.  This is the reason why IUI is proposed as the first line of fire to all couples who could benefit from it. The chances depend largely on three factors:  indication, the type of stimulation and the age of the woman. The indication is the reason why you have resorted to insemination.  In most cases infertility really isn’t present, but hypo-fertility, that is a spontaneous pregnancy is possible but the chances are diminished because of the presence of male or female abnormalities: permeable but slightly altered tubes, imperfect ovulation, lessening of the number and mobility of the spermatozoa, alteration of their form.  In reality IUI cannot be considered a real treatment, because once it has ended everything remains the same as it was originally.

Its objective is not therapeutic but substantial: IUI aims at optimising the chances of pregnancy by guaranteeing as perfect an ovulation as possible, and bringing close to the tube a slightly higher number of spermatozoa than what would be present in simple sexual intercourse.  In this context, it is impossible to precisely evaluate the influence of the different factors of infertility because in the majority of cases these are related.  Pure cases, in which a single factor is present, are too rare to allow statistical calculation except in the case of donor sperm, because in this case the sperm has proven fertility and the results are higher than average: 15.6% universally, but 20.3% for women less than 35 years old 9.1% between ages 35 and 39 and 6.4% after forty years.

Disclaimer: the information provided on this site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician.

venerdì 21 marzo 2008

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