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  » Infertility  »  Artificial insemination for infertility

Intrauterine insemination with partner's sperm can be used as a potentially effective treatment for infertility of all causes in women under about age 45 except for cases with tubal blockage, severe tubal damage , very poor egg quantity and quality , ovarian failure (menopause), and severe male factor infertility. In vitro fertilization with the woman's eggs or IVF with donor eggs are alternatives for couples that are not candidates for artificial insemination.

It is most commonly used for infertility associated with endometriosis , unexplained infertility , anovulatory infertility , very mild degrees of male factor infertility , cervical infertility and for some couples with immunological abnormalities.

It is a reasonable initial treatment that should be utilized for a maximum of about 3-6 months in women who are ovulating (releasing eggs) on their own. It can be reasonable to use it for somewhat longer than this in women with anovulation that have been stimulated to ovulate.

It should not be used in women with blocked fallopian tubes . Tubal patency should be demonstrated prior to performing insemination. This is usually done with an x-ray study called a hysterosalpingogram .

It has very little chance of working in women that are over 40 years old, or in younger women with a significantly elevated day 3 FSH level, or other indications of significantly reduced ovarian reserve .

If the sperm count, motility or morphology is more than slightly low, insemination is quite unlikely to be successful. In that situation, IVF with ICSI is indicated and has high success rates.

How is insemination performed?

1. The woman usually is stimulated with medication to stimulate multiple egg development and the insemination is timed to coincide with ovulation.

2. A semen specimen is either produced at home or in the office by masturbation after 2-5 days of abstinence from ejaculation.

3. The semen is "washed" in the laboratory (called sperm processing or sperm washing). By this process, the sperm is separated from the other components of the semen and concentrated in a small volume. Various media and techniques can be used to perform the washing and separation, depending on the specifics of the individual case and preferences of the laboratory. The sperm processing takes about 20-60 minutes, depending on the technique utilized.

4. The separated and washed specimen consisting of a purified fraction of highly motile sperm is placed either in the cervix or high in the uterine cavity using a very thin, soft catheter.

Most programs have the woman remain lying down for 5 minutes following the procedure, although this has not been shown to improve pregnancy rates. Since the sperm is above the level of the vagina, it will not leak out when she stands up.

This procedure, if done properly, usually seems similar to a pap smear for the woman. There should be little or no discomfort.

Pregnancy rates

Success rates for intrauterine insemination vary considerably and depend on the age of the woman , type of ovarian stimulation (if any) used, duration of infertility, cause of infertility , number and quality of motile sperm in the washed specimen, and other factors. Rates for women over 35 drop off, and for women over 40 are much lower. For this reason, we are more aggressive in "older" women.

Pregnancy rates are lower when insemination is used:

  • in women over 40
  • in women with poor egg quantity and quality
  • with poor quality sperm
  • in women with moderate or severe endometriosis
  • in women with any degree of tubal damage or pelvic scar tissue
  • in couples with a long duration of infertility (over 3 years)

The rates are slightly higher for women that do not ovulate on their own ( anovulation ) that are stimulated to ovulate with medication and then inseminated. This is because it is likely that the sole cause of their infertility is their ovulation disorder - which is overcome with the use of the ovulation stimulating medicine.

For a couple with unexplained infertility, the female age 35, trying for 2 years, and normal sperm - we would generally expect about:

  • 5% chance per month of conceiving and delivering with clomiphene and intrauterine insemination for up to about 3 cycles (lower after 3 attempts)
  • 8% chance per month of conceiving and delivering with injectable FSH (e.g. Follistim, or Pergonal) and insemination for up to about 3 cycles (lower after 3 attempts)
  • 50% chance of conceiving and delivering with one cycle (month) of IVF treatment (at our center - pregnancy rates vary greatly between IVF clinics

Ovarian stimulation with clomiphene citrate versus stimulation with injectable gonadotropins (Pergonal or Follistim)

Although there is not universal agreement in published studies or among infertility experts, intrauterine insemination with partner's sperm in conjunction with ovarian stimulation seems to provide higher pregnancy rates than insemination in natural menstrual cycles (without ovarian stimulation).

Insemination combined with ovarian stimulation with injectable gonadotropins provides better pregnancy rates (and higher multiple pregnancy rates) as compared to insemination combined with clomiphene. Injectable gonadotropins usually stimulate more mature eggs to develop than does clomiphene. More mature follicles and eggs leads to more chance for a pregnancy. However, more follicles and eggs also entails more risk for multiple pregnancy. It is a double-edged sword...

How many insemination cycles should be done?

Most pregnancies with insemination using partner's sperm occur in the first 3-4 attempts. The chances for success per month drop off after about 3 attempts and considerably more after about 4-6 unsuccessful attempts. Therefore, this therapy is not usually recommended for more than a maximum of 4-6 cycles. If the reason for infertility is lack of ovulation (anovulation) then it may be more reasonable to try several more cycles (6-12 cycles total).

In vitro fertilization is the next step in treatment after inseminations - and has a much higher success rate per cycle .

Cervical vs. intrauterine insemination

Intrauterine insemination has been shown to be more effective than intracervical insemination. By placing the sperm higher in the female reproductive tract, presumably more are able to get to the egg(s).

Stimulation with injectable gonadotropins plus insemination vs. in vitro fertilization

Studies have compared the effectiveness of these two therapies for unexplained infertility. Pregnancy rates are improved substantially with either method of therapy as compared to no treatment.

Chances for pregnancy are better with in vitro fertilization as compared to gonadotropins plus insemination. However, IVF is more invasive and much more expensive than insemination. Therefore, unless the couple has tubal damage or poor sperm quality, 2-4 insemination cycles are usually attempted before moving on to IVF.

Should one or two inseminations be done per cycle?

There are several published studies that address this issue. Some studies show no improvement in pregnancy rates with two inseminations done on sequential days as compared to one well-timed insemination. Other studies show significantly higher pregnancy rates when two inseminations are done.

A possible explanation for this discrepancy could be that if the single inseminations are not properly timed with respect to ovulation, pregnancy rates should improve if the two insemination protocol provides at least one insemination with appropriate timing.

Any insemination should be carefully timed to occur at or a little before the expected time of ovulation. We know that, at least in some couples, sperm can remain viable in the female reproductive tract and result in fertilization of an egg for five or more days. However, we know from in vitro fertilization that eggs are fertilizable for only about 12-24 hours post-ovulation. Insemination done 24 hours after ovulation is, therefore, very unlikely to result in fertilization and pregnancy (although they might conceive if intercourse occurred earlier that cycle).

Since two inseminations per cycle might result result in some improvement in pregnancy rates, the additional cost and inconvenience could be worthwhile. However, it is probably not warranted on a "cost per pregnancy" basis. Although some infertility clinics perform 2 inseminations per cycle, we usually do just one.

Insemination for male factor infertility

Studies have shown that intrauterine insemination can be effective for some cases associated with poor sperm qualit y.

If the total motile sperm count at the time of insemination is less than 5 million, the chances for pregnancy are much lower than with higher counts.

If the total motile sperm count is below 1 million, success rates are very low. Therefore, in vitro fertilization or donor sperm insemination is usually performed for these cases. However, sperm counts are not perfect predictors of fertilizing potential. Rare pregnancies can occur even with total motile counts of less than one million. The converse is also true - some "normal sperm" (by semen analysis) can not fertilize eggs at all. The biochemical defect at the molecular level is sometimes not apparent when sperm are looked at microscopically.

In vitro fertilization with ICSI is usually required for severe sperm defects.

Approximate chance for getting pregnant with one month of various treatments
Female age under 35, 2 years of trying to conceive

Type of Treatment

Total Motile Sperm Count (in millions)

Less than 1

1-5

5-10

10-20

> 20

Intercourse

(Trying on your own)

.2%

1%

2%

2.5%

3%

Intrauterine Insemination
IUI

.4%

2%

4%

5%

7%

Stimulated IUI

(Ovarian stimulation of female and IUI)

.5%

2.5%

7%

8%

10%

IVF with ICSI:

60%

60%

60%

60%

60%