Insemination- It Takes Two to Tango!

With the exception of in vitro fertilization and associated techniques, no procedure has improved fertility chances for males and females more than insemination, particularly intra-uterine insemination.

Intra-uterine insemination is used to treat both male and female sub-fertility by increasing the chances of egg and sperm meeting, fertilizing and resulting in pregnancy. However, the techniques and supportive laboratory procedures must be well chosen and implemented by practitioners skilled in optimizing the outcomes.

Infertility, affecting 10-15 percent of couples, can be traced to semen and sperm difficulties in about 50 percent of couples. The male evaluation with a semen analysis must be done very early in the work-up of an infertile couple, preferably by an andrology lab certified to perform detailed semen analysis and the fertility-enhancing techniques involving sperm. Labs that are not involved routinely with these specialized studies should not be chosen for the initial semen analysis due to the high variability and misleading results. Only qualified andrology labs should be utilized to procure donor sperm for single-woman insemination or infertile couples where sperm is not available from the woman’s partner.

Insemination means artificially placing sperm into the female reproductive tract. There are two variations- intra-cervical (ICI) and intra-uterine (IUI). By far, the IUI is the preferred method when the sperm have been prepared properly by a qualified technologist. IUI places prepared sperm into the upper aspect of the woman’s uterus and fallopian tubes. Ejaculated semen cannot be placed beyond the cervix due to the high risk of severe cramping, infection and possibly allergic reaction. Most importantly, the sperm separated from the liquid component of the semen can be made more vigorous and likely to fertilize the egg with techniques employed by the andrology lab.

Predicting pregnancy chances for a couple based on semen analysis is an “iffy” proposition at best. There are no absolutes, but experience has taught reproductive specialists that the most important factors are sperm count, motility (how well the sperm move) and morphology (what percentage of sperm are normally formed). The minimum “fertile” parameters are:

• Adequate semen volume 1.5- 5 cc with no viscosity issues or agglutination
• No significant red or white blood cell counts in the semen
• Sperm concentration (density) >20 million/cc
• Motility >60 percent
• Forward progression (swimming) >2 on a scale of 1-4, preferring 3 and 4
• Morphology >60 percent normal generally; or >10 percent normal using the strictest criteria

If abnormal, the male should undergo a urologic examination to determine the causes and possible therapies. Often sperm cannot be improved and inseminations can improve chances of pregnancy. In the absence of sperm, donor sperm can be used for inseminations.

The real values of IUI are more, better and closer! The cervix acts as a filter to the ejaculated semen. Very few sperm actually make it past the cervix and into the vicinity of the woman’s egg as it is ovulated from the ovary. IUI allows more – usually millions compared to hundreds of sperm accomplished by intercourse or ICI, improving the odds of fertilization. IUI allows better sperm to be placed higher into the female reproductive tract, closer to the egg as it travels down the fallopian tube, enhancing the odds of conception.

IUI has been shown to help overcome female fertility challenges as well. It is important that inseminations not be employed until certain criteria have been met. To be effective, a woman must have known normal anatomy – specifically a normal or competent-for-pregnancy uterus. One or both fallopian tubes must be open. Ovulation must be known to take place, and timing of the event is essential to proper timing of IUI. In cases where the woman has an ovulation dysfunction, fertility drugs are used prior to IUI. Specific medical conditions also have shown improvements with IUI, especially when combined with fertility-enhancing drugs. These include endometriosis, recurrent pregnancy loss and unexplained infertility. Success with IUI is based on several key factors:

• Evaluation of all other fertility factors and corrective action applied
• Absolute knowledge of uterine and fallopian tube normalcy
• Expert preparation of the sperm for IUI
• Exact timing of natural ovulation or medication induced timing thereof
• Gentle placement of sperm into the uterus
• Proper monitoring of post-ovulation and pregnancy

Inseminations are in-office procedures that are not much different in perception to the female than a Pap smear. Generally, they are not painful unless anatomic variations make placement of the soft plastic insemination catheter more difficult. Practitioners that routinely perform IUIs are skilled at techniques that can minimize these difficulties and generally have several varieties of catheters that can be utilized to make placement of the prepared sperm into the uterus as comfortable and beneficial as possible. After an insemination, the patient lies comfortably for 10 to 15 minutes and then can resume normal daily activities.

In essentially normal couples, IUI has the potential to hasten conception or overcome subtle difficulties. In couples with marginal male or female factor, IUI is intended to return the couple to “normal” monthly chance of pregnancy of 15-20 percent when employed with natural ovulation. Usually, no more than six cycles of IUI are necessary for success in properly chosen cases.

About the Author
drhommRobert J. Homm, M.D., FACOG is board certified in reproductive endocrinology and infertility in addition to obstetrics and gynecology and currently practices at Fertility and Endocrine Associates in Louisville, which he founded in 1994.

He was the founder and medical director of the first private IVF program in Kentucky in 1994 and together with Kit S. Devine, DNP, APRN, opened Louisville Reproductive Center in 2005, a full-scope fertility center and IVF laboratory.