intrauterine insemination- indications and success rates
TRANSCRIPT
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Intrauterin inseminasyonda hangi endikasyon ne kadar başarı
getirmektedir?
Dr Tevfik Yoldemir BSc MSc
Marmara Üniversitesi
Kadın Hastalıkları ve Doğum A.D.
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Reproductive BioMedicine Online (2014) 28, 300– 309
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Canlı doğum –IUI vs COS-IUIEFAİ
N=664
IUI yapalım mı?
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Canlı doğum oranıAİIUI yapalım mı?
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EFAİ
8 RKÇ, 2550 çift
IUI yapalım mı?
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Prognostik indeks skoru
Human Reproduction Vol.19, No.9 pp. 2019–2026, 2004
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Gebelik oranı tahmini
Human Reproduction Vol.19, No.9 pp. 2019–2026, 2004
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6 ay içinde canlı doğumEFAİ
IUI yapalım mı?
Kötü prognoz, IUI+KOS > BG / KS+Zİİyi prognoz, BG > diğerleri
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4 ay içinde devam eden gebelikEFAİ
IUI yapalım mı?
İyi prognoz, IUI+KOS >Kötü prognoz, IVF>
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6 ay içinde canlı doğumEFAİ
IUI yapalım mı?
Kötü prognoz IUI+KOS veya IVF> IUI - KOSİyi prognoz IUI-KOS > diğerleri
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4 siklus içinde canlı doğumEFAİ
IUI yapalım mı?
IUI veya ICI+KOS >
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Reproductive BioMedicine Online (2014) 28, 300– 309
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Gebelik ve doğum oranları - IUI
Fertil Steril 2014;101:994–1000
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Prognostik skorKOS/IUI prognostik faktörler
7.381
4.58
5.30
3.81
1
23
4
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Prognostik skorKOS/IUI prognostik faktörler
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Canlı Doğum- Erkek subfertilitesiEF
KS+HMG
Kimlere?
IUI = IUI+KOS
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HCG sonrası ovulasyona bağlı siklus sonuçları
EFAİ
Human Reproduction, Vol.26, No.3 pp. 576–583, 2011
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Rüptür olmayan folikül –Tek vs çift IUI
EFAİ
Human Reproduction, Vol.26, No.3 pp. 576–583, 2011
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IUI:Sperm MorfolojisiJ. Van Waart et al ( 2001) Hum Reprod
4%
EF
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IUI: Sperm Morfolojisi – Gebelik OranlarıJ. Van Waart et al ( 2001) Hum Reprod
Referans ≤ % 4 > % 4
Montano-Gauci et al (2001) % 2.6 % 15.6
EF
Montano-Gauci et al (2001) % 2.6 % 15.6
Toner (1995) % 7 % 11.3
Ombelet (1997) % 12.1 % 16.5
Karabinus and Gelety (1997) % 6.5 % 9
Lindheim et al (1996) % 1 % 19.5
Matorras et al (1995) % 10.9 % 13
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IUI Başarısı- Total Motil Sperm Sayısı
Yıkama sonrası : 0,3-20 milyon
• Branigan EF et al., 1999
• Berg U., et al., 1997
• Burr RW et al., 1996
• Huang HY et al., 1996
• Horvath PM et al., 1989
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Erkek subfertilitesinde IUI: Hasta seçimiJ-M van Weert et al (2004) Reprod Biomed Online
• 290 çift, 722 IUI siklusu
• 12 aylık tedavi süresi, en fazla 9 siklüs
• Model I: Bayan yaşı, subfertilite süresi, sekonder subfertilite,
EF
• Model I: Bayan yaşı, subfertilite süresi, sekonder subfertilite, anovülasyon varlığı, servikal faktör, deneme sayısı
• Model II: Model I + Antisperm antikor (ASA)
• Model III: Model II + Yıkama sonrası toplam motil sperm sayısı (en az 1 milyon)
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Erkek subfertilitesinde IUI: Hasta seçimiJ-M van Weert et al. (2004); Reprod Biomed Online
AUC
Model I: 0,59
Model II: 0,65
Model III: 0,67
EF
Model III: 0,67
• Model kullanmadan gebelik oranı %9
• Model I ile gebelik oranını %11’e
• Model II ve III ile gebelik oranını %14’e yükseltmiştir.
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Erkek subfertilitesinde IUI: uygulanacak siklus sayısıJ-M van Weert et al (2004) Reprod Biomed Online
EF
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IUI: Gebeliği etkileyen faktörlerMontanaro G et al (2001) Andrologia
• Erkek Faktörleri
• Morfoloji (% Kruger strict kriteri) % PR
P (poor / %0-4 normal morf) % 2,63
EF
P (poor / %0-4 normal morf) % 2,63G (good / %5-14 normal morf) % 11,4N (normal >14 normal morf) % 24
• Motilite (%)< %50 % 3,8> %50 % 15,5
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IUI: Gebeliği etkileyen faktörlerMontanaro G et al (2001) Andrologia
Sperm morfoloji, motilite ve folikül sayısının gebelik oranları üzerine etkisinin birlikte değerlendirilmesi
EF
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IUI: Kadın yaşı, sperm kalitesi, total sperm sayısıCampana et al (1996) Hum Reprod
EF
>44 yaşında ve <1 mil. tmss’de gebelik yok>44 yaşında ve <1 mil. tmss’de gebelik yok
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IUI: Semen ÖzellikleriZhao et al (2004) J. of Ass Reprod and Genetics
Gruplar semen parametreleri açısından alt gruplara ayrılıp incelendiğinde;
PR p
• İlk (yıkama öncesi) sperm motilitesi >%80 %17,6 0.02
EF
• İlk (yıkama öncesi) sperm motilitesi >%80 %17,6 0.02
• Yıkama sonrası sperm kons 51-100 mil/ml %16,5 0.01
• Toplam motil sperm sayısı 11-100 mil %13,5 0.04
• Progresif motilite 4 (WHO’ya göre A mot.) %13,3 0.02
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IUI: Semen KalitesiOmbelet et al (2003) Reprod Bio Online
• İnsemine edilen motil sperm sayısı > 1x106
olduğunda ilk 3 IUI denemesinin kümülatif gebelik oranları, IVF ile
EFAİ
gebelik oranları, IVF ile benzer
• IUI ilk yöntem olarak tercih edilmeli
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DSO 1999 vs 2010
Human Reproduction, Vol.30, No.5 pp. 1110–1121, 2015
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Spontan vs tedavi sonrası gebelikEFAİ
Human Reproduction, Vol.30, No.5 pp. 1110–1121, 2015
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TMSS – IUI gebeliğiEFAİ
Human Reproduction, Vol.30, No.5 pp. 1110–1121, 2015
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TMSS DSO sınıflaması – IUI gebeliğiEFAİ
Human Reproduction, Vol.30, No.5 pp. 1110–1121, 2015
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Insemine edilen NMS - klinik gebelik
EF
Human Reproduction Vol.19, No.9 pp. 2060–2065, 2004
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İnsemine edilen NMS – IUI EF
Human Reproduction Vol.19, No.9 pp. 2060–2065, 2004
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İnsemine edilen NMS –klinik gebelik
EF
Human Reproduction Vol.19, No.9 pp. 2060–2065, 2004
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Tedavi seçenekleriEFAİEndo
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Tanı – Tedavi – Canlı doğum oranıEFAİEndo
Human Reproduction Update, Vol.10, No.4 pp. 309–316, 2004
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Tanı – Tedavi – Canlı doğum oranıEFAİEndo
Human Reproduction Update, Vol.10, No.4 pp. 309–316, 2004
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EFAİEndo
Human Reproduction Update, Vol.20, No.1 pp. 141–151, 2014
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EFAİEndo
Human Reproduction Update, Vol.20, No.1 pp. 141–151, 2014
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EFAİ
Human Reproduction Update, Vol.20, No.1 pp. 141–151, 2014
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Evre 3-4 endometriozisEndo
Reproductive BioMedicine Online (2014) 28, 590– 598
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Evre 3-4 endometriozisEndo
Reproductive BioMedicine Online (2014) 28, 590– 598
(IUI with natural/ovarian stimulation): IUI without ovarian stimulation in the first three cycles followed by IUI with ovarian stimulation
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Evre 3-4 endometriozisNatural ve IVF ile devam eden gebelikler
Endo
Sadece IUI ile devam eden gebelikler
Reproductive BioMedicine Online (2014) 28, 590– 598
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Evre 3-4 endometriozisEndo
Reproductive BioMedicine Online (2014) 28, 590– 598
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FASTT trialAİ
KSFSH21-39 yaş
Kimlere?
FSH-IUI atlanabilir
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FORT-T TrialAİ
KSFSH
Kimlere?
38-42 yaş
Hemen IVF , olamayacaksa > CC-IUI ve sonra IVF
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Canlı doğumAİ
KSFSH
Kimlere?
Hemen IVF , olamayacaksa > CC-IUI ve sonra IVF
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Açıklanamayan infertilite - KS / Gn
Reproductive BioMedicine Online (2012) 24, 591– 602
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Açıklanamayan infertilite - IUI
Reproductive BioMedicine Online (2012) 24, 591– 602
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Algoritma
Reproductive BioMedicine Online (2012) 24, 591– 602
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Eve götürülecek mesajlar -1
Reproductive BioMedicine Online (2011) 23, 220– 226
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Eve götürülecek mesajlar -2
Reproductive BioMedicine Online (2011) 23, 220– 226
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Eve götürülecek mesajlar -3
Reproductive BioMedicine Online (2011) 23, 220– 226