Effectiveness of stimulated menstrual cycles and Percoll sperm preparation in intrauterine insemination

To examine the usefulness of intrauterine insemination in women with various fertility factors, we retrospectively analyzed data from women treated during 1986 and 1987. Ninety-three patients underwent 1-11 cycles of single or double procedures, for a total of 423 inseminations in 263 treatment cycles. Twenty-six patients (28%) conceived, for a 10% total pregnancy rate per cycle, with 58% of the pregnancies resulting from double inseminations per cycle. An average of two treatment cycles was required to achieve pregnancy. Eight pregnancies (31%) occurred in spontaneous cycles, while 18 (69%) occurred in stimulated cycles. While clomiphene citrate therapy was useful in anovulatory patients, it was of no benefit in ovulatory patients being treated with intrauterine insemination. Human menopausal gonadotropin therapy was of benefit in both ovulatory and anovulatory patients when combined with intrauterine insemination. The live birth rate was higher (75%) in spontaneous cycles than in stimulated cycles (44%). Semen preparation was accomplished by sperm washing in 61% of the pregnancies and by Percoll preparation in 39%. The effectiveness of the discontinuous Percoll gradient for semen preparation for insemination was suggested by a pregnancy rate of 9% per cycle. While the mean sperm count in the pregnant group was 44 million, successful pregnancy was accomplished with a double insemination of 880,000 and 1.16 million rapidly progressive sperm in the first and second inseminate, respectively. The data confirm the important role of intrauterine insemination for the treatment of infertility.     

Papel de la inseminación intrauterina en la era de la fertilización in vitro

Intrauterine insemination is a low-complexity assisted reproduction technology in which previously washed sperm are deposited in the uterine cavity with ovarian stimulation. This invasive technique is well accepted by patients and achieves cumulative pregnancy rates similar to those obtained in a single cycle of more complex assisted reproduction techniques. We compared two methods of assisted reproduction: in vitro fertilization and intrauterine insemination in relation to their effectiveness and cost. We conclude that intrauterine insemination is the first-line treatment in male factor infertility without severe disruption or unexplained infertility; pregnancy can be achieved with 3 to 6 cycles in a high percentage of these cases at lower cost and with lower risk of multiple pregnancy than with in vitro insemination. We did not consider other techniques, such as intracytoplasmic sperm injection, which is also indicated for the treatment of male factor infertility, since this technique requires greater technical and human resources, thus precluding comparison.     

Experience with intrauterine insemination for cervical factor and oligospermia

In the past 100 years, interest in intrauterine insemination for cervical factor has waxed and waned. Recently the advent of in vitro fertilization, with improved methods of sperm washing and preparation, has revived interest in intrauterine insemination as a modality for the treatment of infertility. Twenty-seven couples with infertility resulting from cervical factor and/or oligospermia were entered into our intrauterine insemination protocol. A total of 107 intrauterine inseminations were performed in 85 menstrual cycles. Nineteen couples with a cervical factor as the major factor in their infertility experienced three pregnancies (16%). The remaining eight couples who had oligospermia with or without cervical factor produced no pregnancies. No major complications occurred from this procedure. In view of the low pregnancy rate experienced in this study, we must seriously question the value of intrauterine insemination in the treatment of cervical factors and/or oligospermia.     

One artificial insemination per cycle with donor sperm is as efficacious as two inseminations

Purpose To compare pregnancy rates per treatment cycle of artificial inseminations with donor sperm in patients receiving one versus two inseminations.Methods Retrospective cross-sectioned analysis of 167 patients who underwent 869 cycles receiving one or two donor inseminations were reviewed from 1987 through 1993 at our institution.Results A total of 256 cycles with one donor insemination per cycle resulted in 21 pregnancies and a cycle of fecundity of 8.2%, and 613 cycles with two donor inseminations resulted in 35 pregnancies and a cycle fecundity of 5.7%. Life table and logistic cumulative probability analysis of pregnancy occurrence showed no difference between treatment groups.Conclusions These data suggest there are no important clinical differences of cycle fecundity or cure rate in one versus two inseminations with donor sperm. Economic costs of two inseminations may not be justified.Presented in part at the 50th Annual Meeting of the American Fertility Society, San Antonio, Texas, November 5–10, 1994.     

Artificial insemination: a comparison of pregnancy rates with intrauterine versus cervical insemination and washed sperm versus serum swim-up sperm preparations

A four-cycle artificial insemination protocol was undertaken, with luteinizing hormone (LH) timing, to compare washed sperm and serum swim-up sperm preparations and cervical and intrauterine insemination. Of the 75 patients entered into the protocol series, 63 finished all 4 cycles. During the treatment period, 24 patients became pregnant, 20 of whom were donor (AID) pregnancies (out of 52 patients) and 4 were husband (AIH) pregnancies (out of 11 patients). Seventy-five percent of the pregnancies were intrauterine, whereas only 25% were from cervical inseminations. Sixty-two percent of the pregnancies were due to serum swim-up sperm preparations, and 38% were due to washed sperm preparations. The data indicate substantially higher pregnancy rates can be obtained with intrauterine insemination and suggest that additional studies are necessary to determine if the method of sperm preparation significantly influences pregnancy rates.     

Treatment by assisted conception of severe male factor infertility due to spinal cord injury or other neurologic impairment

Purpose This retrospective study evaluated the pregnancy rates of 23 couples with male factor infertility due to traumatic spinal cord injury (N = 21), multiple sclerosis (N = 1) or transverse myelitis (N = 1).Methods Ovulation induction by clomiphene citrate or gonadotropins was used in combination with intrauterine insemination as an initial approach for assisted conception in all but one couple.Results Six pregnancies occurred in 60 cycles of intrauterine insemination (mean of 2.6 cycles). In this group, the cumulative pregnancy rate was 26%. Six couples who failed after a total of 33 intrauterine insemination cycles (mean of 5.5 cycles), and 1 couple with no previous intrauterine insemination cycles, initiated 10 cycles of in vitro fertilization (mean of 1.4 cycles). In this group, five pregnancies occurred. The pregnancy rate was 71%.Conclusion We conclude that ovulation induction in combination with intrauterine insemination offers an effective initial therapy of severe male factor infertility due to spinal cord injury.Presented at the 50th Annual Meeting of the American Fertility Society, November 5–10, 1994, San Antonio, Texas.     

Sperm washing and intrauterine insemination for cervical factor, oligospermia, immunologic infertility and unexplained infertility

The cumulative pregnancy rate was evaluated for 56 couples undergoing 227 intrauterine inseminations (IUIs) after sperm washing. The indications for IUI were cervical factor, oligospermia, immunologic infertility and unexplained infertility. The overall pregnancy rate was 21.4%, with a 0.289 cumulative probability of conception after six cycles. Within each category the pregnancy rates were 25% for cervical factor, 60% for women with antisperm antibodies, 20% for men with antisperm antibodies and 7% for oligospermia.     

Delayed timing of intrauterine insemination results in a significantly improved pregnancy rate in female partners of quadriplegic men

Objective: To review pregnancy rates obtained with three protocols used during development of a successful therapy for infertility in couples in which the male partner had spinal cord injury.

Design: Retrospective chart review.

Setting: Private infertility center.

Patient(s): Eleven quadriplegic men and their spouses undergoing intrauterine insemination.

Intervention(s): Protocol 1: Intrauterine insemination was performed 24 hours after the LH surge was detected in unstimulated cycles. Sperm were prepared by standard sperm washing. Protocol 2: Female partners were stimulated with clomiphene citrate and hCG. Sperm were inseminated 32–34 hours after hCG injection. Sperm preparation was by serum swim-up or density gradient preparation. Protocol 3: Identical to protocol 2, except the insemination was delayed to 38–40 hours after hCG injection.

Main Outcome Measure(s): Pregnancy rates.

Result(s): Five patients were enrolled into protocol 1 and underwent a total of 19 inseminations with no subsequent pregnancies. They then underwent protocol 2, but no pregnancies resulted from inseminations. Four of the original couples, along with six additional couples, underwent insemination in protocol 3. A total of 19 inseminations were performed, and 6 of the 10 patients (60%) became pregnant. The success of insemination at 38–40 hours after hCG administration was significantly better than that of the initial two protocols (P<.05). No differences were observed in sperm quality between protocol 2 and protocol 3. Overall, 73% (8 of 11) of the patients became pregnant.

Conclusion(s): Intrauterine insemination 38-40 hours after the hCG injection results in an improved chance of pregnancy. These results indicate that many couples with spinal cord injury-associated male infertility can be treated with intrauterine insemination of sperm treated by serum swim-up, with a high probability of success.     

Optimization of artificial inseminations with donor semen: a four-year experience

OBJECTIVE: Our aim was to analyse the results of a donor insemination program using ovarian stimulation, swim-up sperm preparation and intrauterine insemination proposed to women with a maximum age of 39. Incidence of several clinical and biological parameters on success rates was investigated. PATIENTS AND METHODS: Retrospective analysis of the results of 249 cycles performed in 106 couples during a four-year period is reported. RESULTS: Overall pregnancy rate of 28.1% and delivery rate of 22% per cycle were achieved, with a multiple pregnancy rate of 11.4%. Most of the pregnancies (84%) were obtained before the fourth insemination. Among the different parameters studied the total number of motile sperm inseminated was found to be the most important factor for success rate: pregnancy rate per cycle reached 40.4% if more than 1.5 million progressive sperm were inseminated vs. 24.7% if they were less than 1.5 million (P<0.05). DISCUSSION AND CONCLUSION: In precise conditions, outcome of inseminations with donor semen can reach satisfying pregnancy rates, being a valuable help for couples suffering of long-time infertility.     

Intrauterine insemination-ready versus conventional semen cryopreservation for donor insemination: a comparison of retrospective results and a prospective, randomized trial.

OBJECTIVE: To compare fecundity rates following intrauterine insemination (IUI) with donor sperm frozen conventionally versus an IUI-ready preparation. DESIGN: Both retrospective results and a prospective, randomized study where recipients were assigned to one of two sperm cryopreservation methods in each cycle of intrauterine insemination are reported. SETTING: University-based infertility practice, affiliated private practices, and andrology laboratory. PATIENT(S): Women desiring therapeutic insemination in an effort to establish pregnancy. INTERVENTION(S): Intrauterine insemination with donor sperm frozen conventionally or by an IUI-ready protocol. MAIN OUTCOME MEASURE(S): Cycle fecundity in donor IUI recipients. RESULT(S): In a retrospective analysis involving 642 inseminations in 209 recipients, 79 pregnancies were recorded for an overall pregnancy rate of 12.3% per insemination (or cycle): 11.3% with IUI-ready sperm and 13.9% with conventionally preserved sperm. In a follow-up prospective, randomized study, the pregnancy rate for IUI-ready sperm preparations was 36% per cycle (14 of 39) whereas that for conventionally preserved sperm was 19.6% per cycle (9 of 46). Thirteen of the 23 pregnancies occurred in the first study cycle of insemination; only two pregnancies were observed in patients undergoing more than four cycles of insemination. CONCLUSION(S): Cycle fecundity for IUI-ready donor sperm is equivalent to conventional cryopreserved sperm based on both prospective and retrospective assessments.     

Intrauterine insemination of washed husband's spermatozoa: a controlled study

We performed intrauterine insemination with washed husband's spermatozoa in 27 couples with clear evidence of impaired sperm mucus interaction due to cervical hostility or immunologic male subfertility and in 30 couples with subnormal semen, but optimal cervical mucus qualities. In each couple insemination cycles were alternated with cycles during which normal intercourse took place. Both types of cycles were monitored for LH. When a clear rise of LH levels could be detected, either IUI was scheduled or intercourse advised for the following day. In the male subfertility group no difference between the pregnancy rates of insemination and intercourse cycles was present. In the group with impairment of sperm-mucus interaction, the pregnancy rate of the insemination cycles was 16%, whereas no pregnancies occurred during intercourse cycles.     

Life-table analysis of artificial insemination pregnancy rates for couples with male factor and idiopathic infertility

Background :  In the summer of 2002, standard guidelines for the application of assisted reproductive technology were reported by a research group of the Ministry of Health, Labor and Welfare. The present study aimed to examine the relationship between the number of cycles of artificial insemination and the cumulative pregnancy rates according to the cause of infertility.
Methods :  Patients who experienced their first cycle of artificial insemination during the period of January 1999–December 2002 were included in the study and were divided into a male factor infertility group and an idiopathic infertility group. Cumulative pregnancy rates resulting from artificial insemination with the husband's semen were calculated by the life-table approach.
Results :  During the study period, 139 couples entered the assisted reproduction program and underwent 581 cycles. Significant differences were observed in cumulative pregnancy rates between the two groups.
Conclusion :  It is recommended that couples with male factor infertility and who fail to conceive within six or seven cycles of intrauterine insemination, consider a modification of treatment strategy such as in vitro fertilization, because cumulative pregnancy rates of this group were reached at a plateau within six or seven cycles. In contrast, patients with idiopathic infertility, the cumulative pregnancy rates appeared to increase constantly with each subsequent cycle. It is important to consider modifications of treatment strategy in the light of the cause of infertility. (Reprod Med Biol 2004; 3 : 27–31)     

Intrauterine inseminations with washed human spermatozoa

The success of intrauterine inseminations with washed human spermatozoa was evaluated in four groups of patients. The first two groups were couples in whom either the man or the woman had detectable circulating sperm-agglutinating antibodies. The third group included couples where the woman exhibited hostile or absent cervical mucus, whereas the fourth group represented couples with oligozoospermic males. The couples underwent 3.7 +/- 2.1 insemination cycles, with a 30% overall pregnancy rate for all four groups. Intrauterine inseminations of women with hostile cervical mucus yielded a 68% conception rate. Couples with either male or female serum sperm-agglutinating antibodies showed 25% and 40% pregnancy rates, respectively. However, none of the couples with oligozoospermic males achieved pregnancy. Intrauterine inseminations with washed human spermatozoa thus represent a satisfactory method of achieving pregnancy in women with hostile cervical mucus and in couples with circulating sperm agglutinating antibodies. Couples in whom oligozoospermia has been identified as the principal cause of infertility do not seem to benefit from this therapy.     

Treatment of refractory infertility by transcervical intrauterine insemination of washed spermatozoa

One hundred thirteen couples with either male factor, cervical factor, endometriosis, or idiopathic infertility of at least 3 years' duration were treated by intrauterine insemination (IUI) of washed motile sperm. Of the 68 women who became pregnant or completed at least three cycles of insemination, the overall pregnancy rate was 38.2%, with a mean of 1.7 treatment cycles per pregnancy. The average pregnancy rate per treatment cycle was 11.4%. Women who did not become pregnant underwent an average of 4.7 treatment cycles. Importantly, only two pregnancies occurred independent of treatment in 113 couples. In the male factor group, the pregnancy rate was 42.9% (n = 21). In women with a cervical factor, 34.5% became pregnant (n = 29); in idiopathic infertile couples or women suffering from endometriosis, there was a pregnancy rate of 38.9% (n = 18). The presence of sperm antibodies in either the male or female partner significantly lowered the pregnancy rate (6.7%) when compared with couples without sperm antibodies (50.0%). The authors conclude from these observations that IUI with washed sperm is a successful mode of therapy, especially in the case of males with asthenozoospermia.     

Semen quality and intrauterine insemination

There is good evidence in literature that intrauterine insemination (IUI) is the best first line treatment and most cost-effective procedure for moderate male factor subfertility. It seems very difficult to identify individual semen parameters predicting the likelihood of pregnancy after IUI. This can be explained by a lack of standardization of semen analysis, but many other methodological variables may also influence IUI success rates such as the patient selection, type of ovarian stimulation and number of inseminations per cycle. A review of the literature confirmed that sperm morphology using strict criteria and the inseminating motile sperm count (IMC) after sperm preparation are the two most important sperm parameters to assess the real impact of semen quality on IUI outcome. A universal threshold level above which IUI can be performed with acceptable pregnancy rates has not been determined yet, although IUI success seems to be impaired with <5% normal spermatozoa and an IMC of <1 x 10(6). Until now, no method of sperm preparation has been shown to be superior with regard to pregnancy rate after IUI. Whether supplementation of culture media with substances such as antioxidants and platelet activating factor may improve the results remains the subject of further research.     

Predictors of success with the use of donor sperm

OBJECTIVE: This study was undertaken to assess the effect of multiple factors that influence the success rate and time to conception among couples undergoing donor sperm insemination. STUDY DESIGN: A retrospective analysis of 960 cycles of frozen donor sperm insemination was performed at the University of Florida. Cycle pregnancy rates and cumulative probability of pregnancy were compared using several variables. RESULTS: The pregnancy rate was 12.1% per treatment cycle, and the cumulative probability of pregnancy exceeded 80% for the entire cohort. Seventy percent of pregnancies resulted in a liveborn infant. Age had a profound impact on the cycle pregnancy rate. The cycle pregnancy rates for women younger than 30 years, between the ages of 30 and 35 years, between the ages of 35 and 40 years, and older than 40 years were 15.8%, 14.6%, 8.2%, and 0%, respectively. There was a trend toward higher cycle pregnancy rates in women with prior pregnancies versus women without prior pregnancies of 14.4% and 12.3%, respectively. Parity had no effect on the cycle pregnancy rate or the cumulative probability of pregnancy. There was a trend toward higher cumulative probability of pregnancy in women whose partners were azoospermic versus oligospermic. There was no difference in pregnancy rates obtained with the Percoll wash gradient versus the Isolate gradient. At >20 million total motile sperm per insemination, there was no threshold above which the pregnancy rate was improved. CONCLUSION: The most significant influence on pregnancy rates in the donor sperm insemination program at the University of Florida was maternal age. Nulligravidity and a diagnosis of mild oligospermia in the man may have a negative impact on pregnancy rates.     

A continuous-step density percoll gradient for use in AIH and life table analysis of pregnancy rates

For use in artificial insemination with husband's semen (AIH), a continuous-step Percoll density gradient technique was used to wash and concentrate sperm from ejaculate. To evaluate usefulness, the pregnancy rates were analyzed by the life table method. 1. After washing by the continuous-step Percoll density gradient method, sperm density increased from 28.8 X 10(6)/ml (original semen) to 40.9 X 10(6)/ml and sperm motility improved from 52.4% (original semen) to 77.0% respectively. 2. A group of 119 infertile patients whose diagnosis involved oligoasthenozoospermia, cervical factor and unexplained infertility were selected for AIH. After 640 insemination cycles, 37 women conceived with a pregnancy rate of 31.1%. By using life table analysis, the cumulative conception probability rate reached 0.652 after 13 insemination cycles. 3. Cumulative pregnancy rates by diagnostic category were 0.494 in male factor and 0.745 in cervical factor after 12 cycles, respectively. 4. The poorest results were obtained in unexplained infertility with a cumulative pregnancy rate of only 0.355 after 12 cycles. 5. In the follow up study, 24 viable babies were born and seven (18.9%) resulted in spontaneous abortion in the first trimester. These results indicate that the continuous-step Percoll density gradient technique is useful for improving the pregnancy rate in AIH.     

Intrauterine insemination: the University of Minnesota experience

Forty-five patients initiated intrauterine insemination between October 1981 and August 1983. Indications for insemination included poor semen (count less than 20 X 10(6)/ml and/or motility less than 40%), poor cervical mucus, presence of sperm antibodies, unexplained poor postcoital tests, or various combinations of the above. During this time period, 374 inseminations were performed in 163 cycles and resulted in eight pregnancies in the 45 patients receiving artificial insemination by homologous donor, for an overall pregnancy rate of 17.4%. The fact that five of the pregnancies occurred in the first insemination cycle and two in the second cycle was felt to indicate a cause-and-effect relationship. A trial of intrauterine insemination in selected patients would appear to be warranted.     

Platelet-activating factor improves intrauterine insemination outcome

OBJECTIVE: Our purpose was to investigate intrauterine insemination pregnancy rates after human spermatozoa exposure to platelet-activating factor. STUDY DESIGN: Spermatozoa were incubated with platelet-activating factor in sperm-washing medium before intrauterine insemination. Patients whose sperm were incubated with sperm-washing medium alone served as controls. Pregnancy outcome was determined by ultrasonography (fetal heartbeat). RESULTS: Patients whose sperm were treated with exogenous platelet-activating factor had a significantly (P <.05) higher pregnancy rate (40%) than patients (20%) not receiving treatment. CONCLUSION: Inclusion of platelet-activating factor into a semen processing protocol, before intrauterine insemination, will significantly improve pregnancy rates. Platelet-activating factor may have a stimulatory effect on centriole-intact spermatozoa, enhancing their motility and fertilization success and resulting in improved pregnancy rates. Additional studies will elucidate the reproductive significance of platelet-activating factor activity in spermatozoa and its role in the establishment of pregnancy.     

A randomized comparison of three insemination methods in an artificial insemination program using husbands' semen

OBJECTIVE: To compare pregnancy rates with single intrauterine insemination (SIUI), double intrauterine insemination (DIUI) and fallopian tube sperm perfusion (FSP). STUDY DESIGN: Ninety patients undergoing a standard ovarian stimulation regimen were randomized to receive SIUI, DIUI or FSP. The end point was either pregnancy or completion of 3 treatment cycles without pregnancy. RESULTS: There were no differences in demographic data or ovarian responses. The total number of motile spermatozoa inseminated in the FSP group was significantly lower than in the SIUI group. No significant differences were found in pregnancy rate per cycle or patient, multiple pregnancy rate and outcome of pregnancy between the 3 groups. CONCLUSION: Similar pregnancy rates were achieved after SIUI, DIUI and FSP during stimulated cycles.