Intrauterine insemination: a critical review

Intrauterine insemination with semen of oligozoospermic men: effectiveness of the continuous-step density gradient centrifugation technique

There has been an argument as to whether the intrauterine insemination (IUI) substantially improves pregnancy rate in cases of oligoasthenozoospermia. The present study evaluates the efficiency of the IUI with the use of the life table analysis. The insemination was performed after washing and concentrating sperm using the continuous-step density gradient centrifugation reported in our previous papers. The number of IUI cycles studied was 222 (46 couples), in 13 cases of which pregnancy was established with a pregnancy rate of 28.3%. The cumulative probability of conception reached to 57% at the eleventh cycles of the IUI treatment. These results suggest that the potential efficiency of the IUI for the oligo-asthenozoospermic cases is high if the sperm is processed in a proper method.

Motile sperm recovery from fresh and frozen-thawed ejaculates using a swim-up procedure

The recovery of motile sperm in swim-ups from fresh semen that was washed and centrifuged one time was 33% and after 2 washes and centrifugations was 22%. The recovery rates for frozen-thawed semen were only 7% and 5%, respectively. The straight line velocity of sperm was increased after sperm swim-up, whereas changes to the lateral sperm head movement were not as evident. However, the dramatic loss in motile sperm numbers especially after swim-up from thawed semen indicate that more efficient methods of isolating motile sperm from thawed semen may be required.

Controlled ovarian hyperstimulation and intrauterine insemination for treatment of infertility

Empirical therapy for subfertility using assisted reproductive technologies recently has gained popularity; however, the cost-effectiveness of these therapies, compared with an untreated control group, has not been established. Similarly, there has been no comparative cost analysis of the utility of controlled ovarian hyperstimulation and IUI in the management of the same condition. Significant PRs in untreated couples with subfertility mandate the design and execution of controlled trials to ascertain the role of controlled ovarian hyperstimulation and IUI in infertility therapy. Various disorders of subfertility have been treated with controlled ovarian hyperstimulation and IUI. The rationale for this therapy is the increase in gamete density at the site of fertilization, as with GIFT and IVF when used for management of the same problems. The live birth rate per initiated cycle and risk of complications are similar to results recently reported for GIFT and IVF. The utility of controlled ovarian hyperstimulation and IUI still remains controversial. When the relatively low direct and indirect costs of controlled ovarian hyperstimulation and IUI are considered, acknowledging the lack of prospective, controlled studies, this procedure appears to be at least as cost-effective as GIFT and IVF.

Pregnancy rates after timed intercourse or intrauterine insemination after human menopausal gonadotropin stimulation of normal ovulatory cycles: a controlled study

Forty-eight patients with male (n = 16) or idiopathic (n = 32) infertility were stimulated with human menopausal gonadotropin. Intrauterine insemination (IUI) or natural intercourse were performed after either human chorionic gonadotropin (hCG)-induced or spontaneous, urinary luteinizing hormone (LH) surge-monitored ovulation. A total of 148 cycles were analyzed. In 40 cycles treated with hCG-induced ovulation and IUI, 3 (7.5%) patients conceived, whereas 37 women accomplished natural intercourse after hCG-induced ovulation and 2 (5.5%) became pregnant. When inseminated after a spontaneous LH surge, 3 (8.8%) of 34 patients achieved a pregnancy; no conception occurred in 37 spontaneously ovulatory cycles combined with timed intercourse. Pregnancy rates did not substantially differ between the treatment modalities or between mono-ovulatory and polyovulatory cycles. The cycle characteristics between spontaneous ovulatory and hCG-induced cycles significantly did differ.

A comparative analysis of the cycle fecundity rates associated with combined human menopausal gonadotropin (hMG) and intrauterine insemination (IUI) versus either hMG or IUI alone

Human menopausal gonadotropin (hMG) superovulation combined with washed intrauterine insemination (IUI) has been advocated for the treatment of various forms of infertility when more traditional therapy has failed. To assess the relative efficacy of combined treatment with hMG and IUI compared with either hMG or IUI alone, pregnancy outcomes of the three treatment groups were compared in couples having infertility because of male factor, cervical factor, endometriosis, or unexplained. A total of 751 cycles were analyzed from 322 couples. The mean cycle fecundity rate associated with hMG/IUI therapy was significantly higher than either hMG or IUI therapy alone for all patients (hMG/IUI = 19.6%, hMG = 6.3%, IUI = 3.4%). The improvement in cycle fecundity rates with hMG/IUI therapy was also observed when the couples were separated by infertility diagnostic groups: male factor (hMG/IUI = 15.3%, hMG = 4.4%, IUI = 3.0%), cervical factor (hMG/IUI = 26.3%, hMG = 7.9%, IUI = 5.1%), endometriosis (hMG/IUI = 12.85%, hMG = 6.6%), and unexplained infertility (hMG/IUI = 32.6%, hMG = 5.5%, IUI = 0%). Moreover, in patients who had failed to conceive with hMG or IUI alone, the cycle fecundity rate when they were switched to hMG/IUI therapy equaled that of patients who received combined therapy from the onset. We conclude that cycle fecundity rates and cumulative pregnancy rates are significantly greater using a combination of hMG and IUI compared with either modality alone in the treatment of male factor, cervical factor, endometriosis, or unexplained infertility. Indeed, in couples with nontubal related infertility, cycle fecundity rates with hMG/IUI approach the rates seen with in vitro fertilization and gamete intrafallopian tube transfer.

Antisperm antibodies in women undergoing intrauterine insemination

Intrauterine insemination is widely used for the treatment of infertility as a result of cervical or male factors or empirically before in vitro fertilization or gamete intrafallopian transfer. This study was designed to confirm or refute the theoretical concern that intrauterine insemination may induce antisperm antibodies in such women. Serum and cervical mucus were obtained at the first, fourth, and sixth intrauterine inseminations. The serum was screened by the Immunobead test for IgG and IgA. If screening results were positive (greater than 10% binding), antisperm antibodies were titered by the microimmobilization and microagglutination tests. The Immunobead test was performed on the cervical mucus after liquefication with bromelin. Ninety-three patients were followed up prospectively. Of these, 40 completed six intrauterine insemination cycles and the remaining 53 completed four cycles. Low transient antisperm antibody levels were detected in 10.8% of the patients and would not be expected to affect the prognosis for fertility. It is concluded that intrauterine insemination does not induce significant antisperm antibody production in women.

Intrauterine insemination does and clomiphene citrate does not improve fecundity in couples with infertility due to male or idiopathic factors: a prospective, randomized, controlled study

In the present prospective study we compared, in terms of pregnancy rates, the differences between intrauterine insemination (IUI) of in vitro capacitated husband's semen and timed natural intercourse in spontaneous or clomiphene citrate (CC) stimulated cycles. A rapid urinary luteinizing hormone peak detection test was used for timing of ovulation. Forty patients suffering from longstanding infertility of male (n = 17), cervical (n = 2), and idiopathic (n = 21) origin were randomly assigned into four distinct treatment modalities during 4 consecutive cycles. A total of 132 cycles were analyzed. In 35 cycles treated with CC plus IUI, five conceptions were achieved, whereas three pregnancies occurred in 32 inseminated spontaneous cycles. Only 1 patient conceived after timed intercourse in 31 CC stimulated cycles, and no pregnancy resulted from 34 spontaneous cycles combined with timed intercourse. There was a statistically significant higher conception rate in cycles in which IUI was performed, whereas the use of CC does not seem to improve the pregnancy rate. Analysis of results for other modifying factors did not substantially affect the relative risk (odds ratio) of pregnancy.

Effects of kallikrein on sperm motility, capillary tube test, and pregnancy rate in an AIH program

From 1984 to 1986, 172 couples were enrolled in an artificial insemination homologous (AIH) program, because of negative postcoital test, fair PT, positive PT with unexplained infertility, and impotentia coeundi. Patients were randomly assigned to the following procedures: AIH with native semen (N, n = 68), washed sperm (V, n = 50), semen mixed with kallikrein (K, 5 IE/ml semen, n = 45), and timed intercourse. The overall pregnancy rate (PR) was 22% per couple (13% inseminations, 9% spontaneous). PR from insemination (spontaneous) was 13% (8), 13% (13), 23% (0) in PT negative, fair, and positive patients, respectively, and 18% (9), 13% (7), and 11% (9) in AIH groups N, V, and K. Among in vitro studies with K added semen, an improvement of sperm motility was demonstrated in half of the specimens. In the capillary tube test (CTT), with wives' cervical mucus, a deterioration was more frequently seen than an improvement after 2 h, independent of the early effect of K in semen, K induced changes of CTT were less pronounced when donors' cervical mucus was used. The results of the in vitro studies offer an explanation for the low PR in the AIH program with K.

Intrauterine insemination in subfertile couples

Forty-three subfertile women were treated by intrauterine insemination with washed sperm. Among the couples, infertility was, in 7 cases due to cervical factor infertility, in 17 cases due to subfertile sperm quality, and 19 cases, unexplained. All women ovulated: 9 spontaneously, 26 where treated with clomiphene citrate and 8 with hMG-hCG. One hundred and sixty seven inseminations were performed in 90 ovulatory cycles. Six pregnancies were recorded (14%): three pregnancies among the cervical factor infertility group (42.8%), two among the couples with low sperm quality (11.7%) and one pregnancy in the group with unexplained infertility (5.2%). Thus, it can be concluded that IUI is effective for achieving pregnancy when unfavourable cervical factor is detected. The method is of doubtful value in cases of low sperm quality or unexplained infertility.

Effect of different procedures of semen preparation on antibody-coated spermatozoa and immunological infertility

To assess whether procedures of semen preparation can reduce the proportion of antibody-coated spermatozoa, semen samples with positive direct mixed antiglobulin reaction (MAR) were washed in media supplemented with 10% or 50% fetal cord serum (FCS). Washing reduced the MAR to a negative level, but the MAR was identical to that in the native semen when spermatozoa were resuspended in serum-free medium. Donor spermatozoa, recovered after swim-up in media supplemented with 10% or 50% FCS or after passage through a column with 7.5% human serum albumin (HSA), were incubated in serum samples with both agglutinating and cytotoxic antisperm antibodies. Cytotoxic activity was significantly reduced against sperm filtered over the albumin column.

Gamete intrafallopian transfer vs superovulation with intrauterine insemination for the treatment of infertility

Superovulation with intrauterine insemination (SO-IUI) has been suggested as an alternative to gamete intrafallopian transfer (GIFT), despite the absence of controlled or comparative trials. We retrospectively analyzed all GIFT and SO-IUI cycles performed concurrently from January 1985 to August of 1987 at a single university center. Pregnancy rates were significantly better for GIFT than SO-IUI (P less than 0.001), with an odds ratio of 3.25 (P = 0.001). Stepwise multiple logistic regression identified factors that correlate with pregnancy: absence of endometriosis (P = 0.05), infertility less than 3 years' duration (P = 0.002), TMS greater than or equal to 30 X 10(6) (P = 0.005), and treatment with GIFT rather than SO-IUI (P = 0.001). These data give a first approximation of the increased efficacy of GIFT versus SO-IUI and provide valuable insight into significant confounding variables to be considered when planning a randomized, prospective trial to evaluate these techniques.

The relationship of sperm parameters to cycle fecundity in superovulated women undergoing intrauterine insemination

Semen parameters of raw and prepared (post-swim-up) specimens from 451 cycles of intrauterine insemination (IUI) were analyzed in relation to cycle fecundity in 232 patients undergoing ovarian stimulation with sequential clomiphene citrate/menotropin therapy. Pregnancy occurred in 42 cycles, resulting in an overall pregnancy rate of 17.7%, and a cycle fecundity of 9.3%. Cycle fecundity was positively correlated with the parameters of post-swim-up log sperm density (r = 0.994), and with log total motile sperm inseminated (r = 0.964; inseminates were limited to a maximum of 20 million total motile sperm). Post-swim-up motility did not correlate (r = 0.308) with cycle fecundity; however, most specimens had a motility of greater than 40% post-swim-up. Only one pregnancy occurred when less than 1 million motile sperm were inseminated (38 cycles), which resulted in a cycle fecundity of 2.6% for these cycles. This may represent the threshold of effectiveness for IUI in this setting. Highest cycle fecundity was obtained with an inseminate containing approximately 10 million or more motile sperm. Parameters of raw samples correlated less well with cycle fecundity than did prepared specimens. Analysis of post-swim-up semen parameters can provide useful prognostic information for women undergoing IUI with ovarian stimulation; this information is helpful in counseling patients regarding their chances of success with this therapy.

Intrauterine insemination with washed capacitated sperm cells in the treatment of male factor, cervical factor and unexplained infertility

One hundred and fourteen couples with long standing infertility due to male factor, cervical factor and unexplained infertility were admitted for therapeutic trials with intrauterine insemination of washed, capacitated husband's sperm cells between May 1986 to October 1987 at The Egyptian IVF-ET Center, Cairo, Egypt. Three hundred and sixty-four trials were done (an average of 3.19 trial per patient). Fifty-eight patients got pregnant (16% pregnancy rate per trial). This simple and noninvasive procedure can be considered as an alternative treatment for infertility due to male factor, cervical factor, and unexplained infertility.

Relationship of within-patient semen variability to outcome of intrauterine insemination

To define the subpopulation of infertility patients who would benefit from intrauterine insemination (IUI) with swim-up homologous sperm, the relationship of within-patient semen variability to outcome of IUI was studied. The 61 women in the study had negative workups. Men had at least one semen sample with greater than or equal to 20 x 10(6) sperm/ml. The 6-month cumulative pregnancy rate for all patients was 31.8%. Patients with original sperm motilities consistently greater than or equal to 30% had a higher cumulative pregnancy rate (62.9%) than patients with one or more motility less than 30% (22.0%, P = 0.0015, log-rank test). Patients with post-swim-up motilities consistently greater than or equal to 70% had a cumulative pregnancy rate (51.2%) significantly greater than patients inconsistent for this parameter (15.6%, P = 0.0116). Consistency of sperm motility is a useful parameter for defining the subpopulation of patients who would benefit from IUI.

Pretreatment of sperm with human follicular fluid for borderline male infertility

To test the usefulness of human follicular fluid (FF) in treating male infertility, we incubated washed sperm specimens from 31 couples undergoing intrauterine insemination (IUI), for male and/or unexplained infertility, with either FF or Ham's F-10 medium (Gibco, Grand Island, NY), in alternating cycles in a randomized manner. Semen specimens from 28 men were incubated with either medium or FF. Incubations with FF have increased sperm penetration assay (SPA) scores from 24.8 +/- 17.3 to 34.3 +/- 13.6 (P less than 0.01). Incubation with heat-inactivized FF also has increased SPA scores, although to a lesser extent than noninactivized FF. Seventeen pregnancies occurred in the 31 couples treated by IUI (54.8%), 16 of them in FF-treated cycles (51.6%) and one in "control" IUI cycles (3.2%, P less than 0.01). All pregnancies occurred within four treatment cycles. Thus, IUI after sperm wash and preincubation with FF may be suggested for four to six cycles to couples with male factor and/or unexplained infertility who are reluctant to resort to artificial insemination by donor or adoption, before attempting the more costly and complex in vitro fertilization-embryo transfer procedure.

Intrauterine insemination is not useful in oligoasthenospermia

A prospective randomized study was conducted in 47 couples with infertility due to subnormal semen to compare luteinizing hormone (LH)-timed intrauterine insemination with LH-timed natural intercourse. No pregnancy occurred in 114 cycles of intrauterine insemination with washed sperm. Only one patient conceived during 1 of the 124 natural intercourse cycles. The only complication that occurred after intrauterine insemination was mild abdominal cramp in 3 cycles. The authors conclude that intrauterine insemination is not useful in the management of subfertility due to oligoasthenospermia.

A prospective study on the lack of development of antisperm antibodies in women undergoing intrauterine insemination

To test the hypothesis that intrauterine insemination with washed spermatozoa induces antisperm antibody formation, we measured serum antisperm antibody levels by the Immunobead technique in a population of women receiving exogenous gonadotropins. Antibody levels were measured before therapy (baseline) and then serially during subsequent stimulation cycles, for a maximum of six cycles. Twenty-eight patients underwent intrauterine insemination; each patient served as her own control. An additional 25 patients were treated with exogenous gonadotropins but did not undergo intrauterine insemination; they served as external controls. Antisperm antibody levels in women who underwent concomitant intrauterine insemination were compared with levels in those who did not. Of the 53 enrolled patients, 18 completed six treatment cycles, and 35 achieved pregnancy before six cycles. Forty-five patients (85%) had less than 10% Immunobead binding, six (11%) had binding between 10% and 25% (mean 16%, range 14% to 20%), and two had binding greater than 25% (28% and 42%, respectively). Mean binding was similar (less than 10%) in the intrauterine insemination and external control groups. Eighteen patients conceived in the intrauterine insemination group and seventeen in the control group. Of patients who conceived, all but one had less than 10% Immunobead binding at the time of conception (mean 1.6 months). In patients who did not conceive, there was no difference in Immunobead binding between control and intrauterine insemination groups after 6 months of therapy. Our data do not support the hypothesis that serum antisperm antibody levels, as detected by Immunobead binding, will increase in menotropin-stimulated women undergoing intrauterine insemination over a prolonged treatment period.

Artificial insemination with husband's sperm (AIH): techniques for sperm selection

Artificial insemination with husband's sperm (AIH) attempts to treat infertile couples by solving their particular infertility problems. This review is concerned with detailing and evaluating the experiences of different authors with AIH in infertile couples, types of insemination, and indications for insemination, with emphasis on techniques for sperm selection and separation: glass-wool filtration, separation on albumin columns, washed sperm, swim-up method, and spermatozoa selection in Percoll gradients.

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.

Methods used to improve gamete efficiency

Male factor infertility accounts for a significant percentage of problems in infertile couples. With clinical utilization of the technologies for selection of good-quality spermatozoa from the ejaculate, our ability to successfully treat the severely affected male factor couple has improved. However, it must be remembered that even with current technologies, fertilization success is reduced in these patients but remains above a 50% level. Other factors that can be used in the future to improve on these statistics are being investigated in regard to the in vitro environment for gametes, that is, the type of culture medium, the methods of coincubation of the sperm and egg, and other methods of enhancement of sperm fertilizing potential. However, methods of sperm preparation will achieve improvement in a percentage of these males treated, and can be used to improve fertilization and pregnancy success. It is important to understand the limitations of the zona-free hamster test, but it is also important to use that test as a screening method for sperm handling. By utilizing the SPA to select out the optimal method of sperm preparation, the fertilization and pregnancy outcome can be improved. Overall, the live-birth rate in male factor infertile couples is lower than non-male-factor couples treated by IVF and GIFT. Until more is known about basic spermatozoal function, and the ability to improve that function in affected males, the live-birth rate should not be expected to change substantially.

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.

Life table analysis of intrauterine insemination pregnancy rates

One hundred twenty-eight couples undergoing intrauterine inseminations were retrospectively reviewed. Life table methodology was used to analyze cumulative pregnancy rates and monthly fecundability. Respective 6- and 12-month cumulative pregnancy rates for each diagnostic group receiving intrauterine insemination were: cervical factor, 28.6% and 42.8%; male factor, 16.7% and 16.7%; female immune factor, 66.7% and 100.0%; male immune factor, 37.5% and 68.8%; and empiric treatment, 60.0% and 60.0%. There was no difference in pregnancy rates between sperm processed with a swim-up in Ham's F-10 or a two-gradient Percoll system. Abnormal sperm penetration assay results in patients with male factor did significantly (p = 0.05) lower the pregnancy rate. It is concluded that if no pregnancy has occurred after six cycles of inseminations, further workup or other treatment may be initiated, but additional pregnancies can be achieved from the seventh through the twelfth cycles of intrauterine insemination.

Multiple gestation is associated with the use of high sperm numbers in the intrauterine insemination specimen in women undergoing gonadotropin stimulation

Over a 27-month period, the authors observed 70 pregnancies in 66 women following intrauterine insemination (IUI) in conjunction with human menopausal gonadotropins/human chorionic gonadotropin (hMG/hCG) stimulation. Excluding ectopic pregnancies (n = 3) and spontaneous miscarriages (n = 15) during the first 10 weeks of gestation, 14 of the 52 pregnancies (27%) included multiple fetuses: nine twins, four triplets, and one quadruplet. Analysis of patient characteristics and clinical management, as well as semen characteristics of the conception cycle, revealed a significant correlation between gestation type (multiple versus singleton) and the total number of motile sperm in the IUI inseminate (P less than 0.01, Fisher's exact test). General linear models procedures did not identify additional significant relationships between various combinations of parameters examined and the gestation type. The authors conclude that IUI with high numbers of motile sperm constitutes a risk factor in the genesis of multiple gestation. The risk of multiple gestation rises significantly when the inseminate contains more than 20 million motile sperm.

The treatment of normospermic infertility by gamete intrafallopian transfer (GIFT)

Gamete intrafallopian transfer (GIFT) was applied in 207 treatment cycles in 73 couples. The pregnancy rate in cycles with only one (2/21, 9.5%) or two (2/29, 6.9%) oocytes transferred was significantly less than that in which four oocytes (36/116, 31.0%) were replaced. The collection of more than four oocytes did not influence the pregnancy rate in that treatment cycle. The overall pregnancy rate was 24.2% (50 of 207) and was similar in the four infertility groups studied (non-occlusive tubal disorders, endometriosis, cervical factor and unexplained infertility) with 28 (56%) of the pregnancies delivered at greater than or equal to 20 weeks. The pregnancy wastage included 4 (8%) ectopic pregnancies and 3 (6%) late pregnancy losses. The 12 multiple pregnancies occurred following the transfer of three and four oocytes.

Spermatozoa selection in discontinuous Percoll gradients for use in artificial insemination

In a preliminary study of the ejaculate of 93 men, changes in motility and hypo-osmotic swelling before and after sperm separation by discontinuous Percoll gradients were evaluated. Both parameters improved significantly (P less than 0.01) in Percoll-separated spermatozoa. In a second stage, 99 couples underwent intrauterine insemination of separated semen by Percoll gradients. The population had infertility for a mean of 5.6 years. In a 1-year period, a total of 344 intrauterine insemination cycles were completed. Failure was considered when conception did not occur within four treatment cycles. The mean number of cycles per successful couple before pregnancy was 1.52. An overall 21% pregnancy rate was achieved (16% for oligoasthenospermia and 24% for asthenospermia). Sperm separation in Percoll gradients is a useful technique for intrauterine insemination in some cases of male subfertility.

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.

Factors influencing maintenance of sperm motility during in vitro processing

Addition of serum to culture medium during washing of sperm was shown to significantly improve sperm motility upon subsequent 24-hour incubation, distinct from the beneficial effects of adding serum after washing. Commercial sources of human and bovine albumen tested did not preserve motility as well as serum, but addition to serum showed that the lesser effect was probably due to toxic contaminants. One of the most commonly available disposable plastic syringes was found to be markedly toxic to sperm. The materials found to have sperm toxicity also manifested toxicity to mouse embryos. These findings show that a similar degree of caution is advisable in testing of materials contacting sperm in vitro to that which has become standard practice for culture of human embryos.

Effect of washing on sperm surface autoantibodies

This study tested the hypothesis that immediate washing "removes" sperm surface antibodies. Nine ejaculates with antisperm antibodies were studied. Separate portions of each ejaculate were washed by centrifugation (Shulman's method) as soon as possible after production (0-h) and 2 h later (2-h). In four samples, portions were also washed by a simple swim-up migration started at 0-h. Washed sperm were tested for surface antibodies using the immunobead binding test. The number of sperm with bound IgG antibodies at 0-h was significantly less than that at 2-h (P less than 0.001) but no significant difference was found in respect of IgA antibodies. Swim-up migration yielded results similar to those of centrifugation and had the advantage of selecting highly motile sperm. The potential application and implication of these findings are discussed.

Superovulation with intrauterine insemination in the treatment of infertility: a possible alternative to gamete intrafallopian transfer and in vitro fertilization

In vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT) are used to treat intractable infertility in women with no distortion of the pelvic viscera, despite the lack of controlled trials demonstrating efficacy. The mechanism of any purportedly enhanced cycle fecundity in ovulatory women without significant distortion of the pelvic viscera is unclear, but both GIFT and IVF-ET increase the number of male and female gametes at the site of fertilization. Intrauterine insemination (IUI) during human menopausal gonadotropin (hMG)-stimulated superovulatory cycles has similar potential but does not require oocyte retrieval. To evaluate the possibility that simply increasing the number of gametes at the site of fertilization might account for pregnancies attributed to IVF-ET and GIFT, the authors retrospectively analyzed the outcome of couples undergoing IUI during hMG cycles between 1983 and 1986 in women with normal pelvic anatomy. IUI during hMG-stimulated cycles yielded a cycle fecundity (f) of 0.17 for endometriosis, 0.29 for cervical factor, and 0.19 for idiopathic infertility, which approaches the fecundity of normal women and equals or exceeds that reported for IVF-ET and GIFT. The authors conclude that treatment with IUI in hMG cycles, alleviating the need for invasive oocyte retrieval, should be considered for inclusion in a randomized, controlled trial in comparison with IVF-ET and GIFT.

Sperm wash in three culture media: maximization of motile sperm recovery during swim-up incubation

Three different culture media commonly used during in vitro gamete manipulations were studied for their efficacy in sperm wash procedure. Highest numbers of motile sperm were recovered at 6 hours following incubation in WT-6 and Ham's F-10 media. However, WT-6 yielded higher motile sperm numbers than Ham's F-10. Swim-up sperm number reached a peak at 3 hours following incubation in BWW. A period of 2 to 6 hours of incubation of sperm pellets overlayed with sperm wash media resulted in highly enriched motile sperm fractions free of dead spermatozoa and seminal debri.

Homologous artificial insemination for oligoasthenospermia: a randomized controlled study comparing intracervical and intrauterine techniques

Homologous artificial insemination (AIH) is used to treat infertility caused by oligoasthenospermia, despite the lack of controlled studies confirming its benefit. This prospective randomized controlled trial was undertaken to determine whether intracervical (IC-AIH) or intrauterine (IU-AIH) homologous artificial insemination improves pregnancy rates in couples with infertility attributable to oligoasthenospermia alone. Twenty couples were randomized to receive IC-AIH or IU-AIH. Sixty-three insemination cycles were completed. During the same study period, 35 cycles with timed vaginal intercourse alone were assessed. Four pregnancies occurred, all following timed vaginal intercourse. No pregnancies resulted from IC-AIH or IU-AIH. This suggests that neither IC-AIH nor IU-AIH is of benefit when oligoasthenospermia is the cause of infertility. Pregnancies previously attributed to AIH may also have been conceived as a result of vaginal intercourse. This confounding effect on the results of AIH should always be considered.

Pharmacologic induction of multiple follicular development improves the success rate of artificial insemination with husband's semen in couples with male-related or unexplained infertility

The use of artificial insemination with husband's semen (AIH) as treatment for couples with male-related or unexplained infertility is often disappointing. The aim of the present study was to evaluate whether the induction of multiple ovulation can increase the pregnancy rates in couples treated with AIH. Multiple follicular development was induced by means of clomiphene citrate (CC) plus purified follicle-stimulating hormone (FSH) in 17 couples undergoing AIH for male-related or unexplained infertility. In spite of the long duration of infertility (greater than 6 years), 10 couples (58.8%) achieved pregnancy within 6 months of treatment. This figure was significantly higher than that obtained in 120 couples who underwent AIH either during spontaneous cycles or after induction of follicular development with CC alone. These results suggest that the availability of multiple mature oocytes increases the conception rate during each cycle, as reported for in vitro fertilization (IVF) programs. It is therefore suggested that a trial of induction of multiple follicular development be performed in couples with male-related or unexplained infertility before their inclusion in protocols for invasive procedures, such as IVF or gamete intrafallopian transfer.

Continuous-step density gradient centrifugation for the selective concentration of progressively motile sperm for insemination with husband's semen

To increase the fertilizability of sperm for use in artificial insemination with husband's semen, it is effective to concentrate progressively motile sperm from whole ejaculated semen. The simple procedure, a continuous-step density gradient technique, was developed to selectively concentrate progressively motile sperm. The ejaculated semen was placed on 6.0 ml of 80% Percoll solution, and the density gradient was formed by mixing the semen and Percoll with an L-shaped rod for two or three strokes. After centrifugation at 400 x g for 30 min, progressively motile sperm were concentrated in the sediment, whereas the immotile sperm and other types of cells remained in the upper part of the density gradient. In most specimens sperm motility was improved by more than 80% regardless of the original motility. Thus, the fertility index (sperm concentration/ml x percentage of motility x 10(-8)). was increased to 7.7 +/- 3.7 times (n = 15).

Improvement in semen quality using glass bead column

Fertilizing ability of semen requires the presence of viable and motile spermatozoa whose surface-membrane integrity is maintained. Male infertility is often the result of these variables being suboptimal. Various in vitro methods have been reported that separate good-quality spermatozoa from such ejaculates. In this study we describe a simple procedure that uses a column of glass beads to separate spermatozoa from poor quality semen. The filtered spermatozoa have significantly better progressive motility and viability and also have enhanced fertilizing capacity. Such a method may have clinical use for semen preparation prior to intrauterine insemination and in vitro fertilization. It may also have a role in the assessment of semen to determine fertilization potential and hence provide prognostic information to infertile couples.

Intracervical versus intrauterine insemination: correlation of outcome with antecedent postcoital testing

Thirty-four infertile women alternated cycles of intracervical insemination (ICI) with whole ejaculate homologous semen (mean, 3.2 cycles/patient) versus intrauterine insemination (IUI) with washed sperm (mean, 3.4 cycles/patient). Twenty of the 34 women had prior postcoital tests consistently demonstrating less than or equal to 3 motile sperm per high-powered field (HPF). Six of those 20 conceived during IUI cycles (30.0%); 0 conceived during ICI cycles (P = 0.06, Mantel-Haenszel chi-square test). The pregnancy rate per IUI cycle was 6/72 (8.3%), compared with 0/66 (0.0%) per ICI cycle, a statistically significant difference (P = 0.04, Fisher's exact chi-square test). Fourteen of 34 women had prior postcoital tests consistently demonstrating greater than or equal to 5 motile sperm per HPF. One of the 14 conceived during an IUI cycle (7.1%), and 2 conceived during ICI cycles (14.3%), a difference that was not significant. The pregnancy rate per IUI cycle was 1/42 (2.4%), compared with 2/42 (4.8%) per ICI cycle (not significant). IUI may be helpful in the management of infertility associated with relatively poor postcoital tests (less than or equal to 3 motile sperm per HPF) but not with relatively good postcoital tests (greater than or equal to 5 motile sperm per HPF).

A prospective study of intrauterine insemination of processed sperm from men with oligoasthenospermia in superovulated women

The effectiveness of intrauterine insemination (IUI) was compared with that of intracervical insemination (ICI) in 49 infertile couples, in whom the major cause for infertility was oligoasthenospermia. All women had ovulation stimulated with either a clomiphene citrate (CC)-human gonadotropin combination or human gonadotropins alone. The ovulatory dose of human chorionic gonadotropin (hCG) was given after adequate estradiol levels were reached. The timing of inseminations was standardized--IUI was 28 hours after hCG and ICI was immediately after hCG administration. Only one insemination per month was performed with either IUI or ICI. The first treatment cycle was assigned randomly to be either IUI or ICI, and subsequent inseminations were alternated. A total of 182 cycles were completed, with 96 IUIs and 86 ICIs. Pregnancy occurred in eight patients, seven with IUI (14.3%) and one with ICI (2.0%); the difference is significant at P less than 0.05. The pregnancy rate per treatment cycle was 7.3% versus 1.2% (P less than 0.001). This study supports the use of IUI with processed sperm in the treatment of infertility due to oligoasthenospermia.