Intrauterine insemination: is it an effective treatment for male factor infertility?

Establishing an intrauterine insemination programme from a nursing perspective

The Centre for Reproductive Medicine in Bristol has been performing simple donor insemination for more than 10 years. Evidence indicates that intrauterine insemination using donated sperm results in higher success rates than intracervical insemination (Ford et al., 1997). As donor insemination at the Centre for Reproductive Medicine gives an overall success rate of 10% (January 1998 -- July 1999), which compares very favourably with other centres licensed by the Human Fertilisation and Embryology Authority, the decision was taken to continue to offer this as the primary service and in addition to offer intrauterine insemination to certain categories of women. Extending the well-established donor insemination service to include intrauterine insemination was a natural progression for nurses already skilled in this area. The aim of this article is to share with other healthcare professionals the key involvement of specialist fertility nurses in the development of an intrauterine insemination programme.

Cryopreservation, screening and storage of sperm the challenges for the twenty-first century

The advent of HIV and the serious nature of the sequelae resulted in a major reassessment of artificial insemination practices in the UK. The development of human semen cryopreservation had enormous impact on reproductive medicine and the availability of cryopreserved quarantined donor semen became a mainstay for the treatment of male infertility in the UK. The regulation and accreditation of assisted reproductive technologies and the introduction of peer-reviewed guidelines have largely standardized clinical and laboratory practice. The introduction of assisted fertilization techniques such as intracytoplasmic sperm injection, testicular sperm retrieval and improved oncology treatments have placed pressure on reproductive biologists and cryobiologists to design and use cryopreservation protocols for the optimum survival of sperm.

Bayesian modeling of the level and duration of fertility in the menstrual cycle

Time to pregnancy studies that identify ovulation days and collect daily intercourse data can be used to estimate the day-specific probabilities of conception given intercourse on a single day relative to ovulation. In this article, a Bayesian semiparametric model is described for flexibly characterizing covariate effects and heterogeneity among couples in daily fecundability. The proposed model is characterized by the timing of the most fertile day of the cycle relative to ovulation, by the probability of conception due to intercourse on the most fertile day, and by the ratios of the daily conception probabilities for other days of the cycle relative to this peak probability. The ratios are assumed to be increasing in time to the peak and decreasing thereafter. Generalized linear mixed models are used to incorporate covariate and couple-specific effects on the peak probability and on the day-specific ratios. A Markov chain Monte Carlo algorithm is described for posterior estimation, and the methods are illustrated through application to caffeine data from a North Carolina pregnancy study.

Intrauterine insemination with donor semen. An evaluation of prognostic factors based on a review of 1131 cycles

OBJECTIVE

To identify prognostic factors influencing the outcome of infertility treatment using intrauterine insemination with donor semen (IUI-D).

DESIGN

Retrospective study of all patients undergoing IUI-D between August 1st, 1990 and July 31st, 1998.

SETTING

University-affiliated infertility clinic.

PATIENTS

Three hundred and five couples undergoing 1131 IUI-D treatment cycles.

MAIN OUTCOME MEASURES

Type of hormonal treatment, number of follicles, length of follicular phase, endometrial pattern, female age, infertility diagnosis and semen quality related to clinical pregnancy rate, cumulative birth rate and multiple gestations.

RESULTS

Throughout the nine year period the overall clinical pregnancy rate per cycle was 22.3%, with an increase from 12.9% in 1990 to 34.6% in 1998. The multiple birth rate was 20.6%. The birth rate per couple was 61.1% after a mean of 3.2 treatment cycles. The pregnancy rate was highest in the first treatment cycle and the cumulative birth rate rose only slightly after the sixth treatment cycle. The following parameters were positively and significantly correlated to a successful outcome of IUI-D: i) the first treatment cycle - compared to the following up to six treatment cycles; ii) number of mature follicles - more than one - at the time of insemination, however, with an unacceptable high rate of multiple pregnancies when more than 3 mature follicles were present; iii) time of insemination after the 12th day in the cycle; iv) insemination after ovulation has occurred and; v) female age under 30 years.

CONCLUSIONS

IUI-D is a simple and inexpensive treatment giving acceptable pregnancy rates for up to six treatment cycles if at least 2 mature follicles have developed at the time of insemination, which implies that hormonal ovarian stimulation and induction of ovulation is used, and ovulation has occurred at the time of insemination, which ought to take place after cycle day (cd) 12 with at least two million motile spermatozoa.

Management of male infertility by assisted reproductive technologies

Among the most popular techniques of assisted reproduction for the treatment of male subfertility and infertility are intrauterine insemination, in vitro fertilization and intracytoplasmic sperm injection. The objective of these techniques is to bring more functional spermatozoa closer to the oocyte in order to promote fertilization. These techniques are thus not a cure per se and are only indicated when no specific or effective treatment is available for the male partner, when this treatment has failed or when the improvement of the female fertility status has also failed. While for moderate oligoasthenozoospermia, intrauterine insemination has proved to be a valid treatment, the outcome after conventional in vitro fertilization is limited because of a high incidence of complete fertilization failure. Since the introduction of intracytoplasmic sperm injection, a reliable method has become available in order to achieve fertilization in vitro. Apart from well from ejaculated spermatozoa, epididymal or testicular spermatozoa too can be used successfully for intracytoplasmic sperm injection. The surgical retrieval of spermatozoa for intracytoplasmic sperm injection has therefore become a routine technique in clinical andrology. Although these techniques have been implemented in everyday infertility practice within a few years of their introduction, many concerns about safety continue to exist. Intracytoplasmic sperm injection must be applied with caution, only when no other treatment option is available and when an appropriate prospective follow-up of the offspring is available.

Management of male infertility

The causes of infertility are known in a small proportion of patients, and only a few are treatable: gonadotrophin deficiency, genital tract obstruction, sperm autoimmunity, coital dysfunction and reversible effects of toxins, drugs or intercurrent illnesses. Other patients have reduced sperm quality or function that may be associated with previous testicular damage, varicocele or non-specific genital tract inflammation. No treatments have been proved to increase semen quality and fertility in this group; intracytoplasmic sperm injection is the most appropriate management if a natural pregnancy is unlikely to occur. Apart from the transmission of genetic and chromosomal disorders and a small increase in the number of sex chromosomal aneuploidies associated with severe spermatogenic defects, the risk of serious adverse effects in intracytoplasmic sperm injection offspring is low. The pathogenetic mechanisms of the most common forms of defective sperm production are unknown, which prevents the logical development of effective treatment.

Female infertility

This article has provided outcome-based evidence using easily understood graphic representation of cumulative pregnancy rates whenever possible for the methods used to investigate and treat female infertility. A scheme of basic routine investigations in specialist practice is developed and clear guidance provided on the choice of treatment for each couple.