IUI or IVF: In Resource Crunch Countries
Infertile couples are usually advised to start their investigations after 12 months of trying to conceive or after 6 months if the female partner is more than 35 years old or immediately if there is an obvious reason to investigate. Each couple undergoes thorough physical examination and a structured battery of investigations. In females this comprises performing hormonal profile, ovarian reserve evaluation, rule out tuberculosis, confirm tubal patency and assess uterine cavity, ovulation assessment and infectious screen in both partners to rule out HIV, Hepatitis B, and Hepatitis C.
Indications of IUI:
• Ejaculatory failure Anatomical (hypospadias) Neurological (Spinal cord injury) Retrograde ejaculation Psychological (Impotence)
• Cervical Factor Poor Cervical mucus Cervical mucus hostility
• Male Factor OAT (oligoasthenoteratozoospermia) Oligospermia Asthenozoospermia Teratozoospermia Azoospermia -AID
• Unexplained Infertility
• Immunological Male antisperm antibodies Female antiserum antibody (cervical, serum)
• Sero discordant couples
Indications for ICSI:
1. TMC˂ 1 million
2. ˂4%normal morphology and TMC˂ 5 million
3. No or poor fertilization in two IVF cycle when TMC>10 million
4. Epididymal or testicular spermatozoa
TUBAL INFERTILITY :
The role of IUI in tubal factor infertility is not adequately covered in western literature. However, it is relevant for developing countries and a few studies that have been performed have shown that there is place for IUI in unilateral tubal block. Since there are not many studies, to appreciate the success rate in such cases is not clear although even one pregnancy without an IVF is an achievement in such cases
MALE FACTOR INFERTILITY:
Poor semen Quality is the single cause of infertility in 20% of infertile couples and is an important contributing factor in another 20-40%. Semen analysis is universally used to assess quality. In 2010, WHO (World Health Organization) defined new reference value for sperm parameters to differentiate between normal and abnormal. However, it does not have good prognostic value. TMSC (Total Motile Sperm Count) has been found to be of value to prognosticate couple undergoing IUI and also in conventional IVF in predicting fertilization failure. It also has a good correlation with spontaneous ongoing pregnancy rate
There is no role of medical therapy for infertility associated with endometriosis. On first laparoscopy itself aim should be to clear all the endometriosis lesions especially the peritoneal and cystectomy should be done in endometrium >3 cm. This increases the chances of spontaneous pregnancy. It is very important that ovarian reserve be assessed before surgery and after surgery and patient informed.
With the given evidence couples especially ˂35 years should be counselled that in mild endometriosis, mild to moderate male factor infertility, unexplained infertility, and one patent tube, ovarian stimulation along with IUI stands equal chance as IVF and hence a uniform policy of 6 IUI cycles followed by 3 cycles of IVF needs to be adopted. In case of blocked tubes, severe endometriosis, severe male factor infertility, poor ovarian reserve, where oocyte donation or surrogacy is indicated IVF/ICSI is the only option. These are broad guidelines and treatment for each patient needs to be individualized. This is especially important for a country like ours where there is resource crunch and also strong economic reasons to delay IVF.
Journal of Basic and Clinical Reproductive Sciences