Received June 10, 1989
andrologia 22, (1): 29-33 (1990)
Institute for the Study of Fertility Serlin Maternity Hospital, Tel-Aviv Medical Centre and Sackler School of Medicine, Tel Aviv University, Tel-Avivhrael.
Intrauterine Insemination in Subfertile Couples. Intrauterine Insemination bei subfertilen Paaren H. Yavetz, A. Mosek, L. Yogev, G. Paz and Z. T. Homonnaj Key words: Intrauterine insemination, semen quality
Summary: 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 hMGhCG. One hundred and sixty seven inseminations were performed in 90 ovulatory cycles. Six pregnancies were recorded (14 Yo) :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 Yo). 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. Zusammenfassung: Mittels einer intrauterinen Insemination wurden 43 subfertile Frauen behandelt, wozu vorher die Spermatozoen gewaschen wurden. Unter diesen Paaren ergab sich in 7 Fallen ein Cervix-Faktor, in 17 Fallen wurde die Subfertilitat durch die Qualitat des Spermas verursacht und in 19 Fallen bestand eine sog. ,,unerklarte Infertilitat". Alle Frauen ovulierten: 9 spontan, 26, wenn sie mit Clomiphen behandelt wurden und 8, wenn eine hMG/hCG-Therapie durchgefuhrt wurde. In 90 Cyclen wurden 167 Inseminationen vorgenommen. Es resultierte eine Schwangerschaftsrate von 14 O/o (6 Graviditaten): hiervon entfielen 3 auf die Frauen mit Cervix-Faktor, 2 auf die schlechte Spermaqualitatsgruppe und 1 auf die Gruppe der unerklarten Infertilitat. Es wird hieraus die SchluBfolgerung gezogen, daB die intrauterine Insemination geeignet ist, um eine Schwangerschaft herbeizufuhren, wenn es sich um einen ungunstigen Cervix-Faktor handelt; dagegen ist der Wert dieser Methode zweifelhaft bei unerklarter Infertilitat und bei schlechter Spermaqualitat. Introduction
Intrauterineinsemination (IUI) has gained popularity in recent years, mainly since the increased expertise gained in sperm handling through in vitro fertilization programmes and the availability of artificial
media for washing sperm. There are at least four indications for the use of IUI: a) infertility due to hostile cervical mucus; b) subfertile sperm quality; c) immunologic infertility; and d) unexplained infertility (Moghissi - 1986). IUI has advantages over intravaginal of cervical insemina-
30
H. Yavetz. M.D. et al.
BBT recording, ultrasound measurement of the dominant follicle, cervical score determination and serum estradiol and progesterone measurements. The men’s fertility evaluation included medical history and physical examination, at least 2 semen analyses and hormonal profile determination. Medical treatment was given to 12 men in order to improve the semen quality: clomiphene citrate to 7 patients, mesterolone to 3 patients and hCG to 2 patients by protocols given elsewhere (Homonnai et al. - 1978). The couples were divided into 3 groups, according to the reason for infertility. Group 1comprised 7 couples in whom the women had viscid or no cervical mucus and negative PCT. The second group included 17 couples in whom the men had Materials and Methods oligoteratoasthenozoospermic semen. Forty-three infertile couples underwent The third group consisted of 19 couples in intrauterine inseminations. The mean age whom no obvious cause for infertility was found (unexplained infertility). of the women was 32.1years (range 23-42) In preparation for IUI, semen was and that of the men 34.7 (range 25-48). couple infertility period was 5.2 years obtained by masturbation and the quality was measured as published (Homonnai et (mean) with a range of 2-14. The women’s fertility evaluation includ- al. - 1980a). After liquification, the semen ed medical history and physical examina- was washed with lOml of Ham’s F-10 tion, recording of basal body temperature medium (Flow Laboratories, Scotland), (BBT), hormonal profile and at least two and centrifuged. The pellet was resuspendpostcoital tests. Hysterosalpingography ed in 0.3 ml of the Ham’s F-10 for insemi(HSG) and diagnostic laparoscopy were nation. This was carried out with the Makperformed as indicated. Twenty-fiveout of ler intrauterine cannula (Haifa, Israel), 43 women had normal hormonal blood while the woman lies in the dorsal litholevel tests. Eleven had elevated levels of tomy position. Insemination was scheprolactin and were given bromocriptine duled in the periovulatory period, accordtreatment. Nine patients were found to ing to the mode of monitoring. In spontaovulate spontaneouslyjudged by the BBT neous ovulators, insemination was done in chart and mid-luteal serum progesterone the periovulatory period as judged by the levels. Twenty-six women were treated last BBT chart. In cycles where clomiwith clomiphene citrate and 8 women with phene citrate was used to induce ovulahMG-hCG therapy to induce ovulation. tion, inseminations were performed HSG was performed in 35 women and according to preovulatory levels of serum diagnostic laparoscopy (in order to ex- estradiol (>200 pg/ml) and progesterone clude mechanical factor) was carried out in ( 1.5ng/ have mechanical problems. Monitoring of ovulation was carried out ml). One to four inseminations were perby at least two of the following methods: formed per cycle. In cases where hMG-
tions since it bypasses the cervix in cases of insufficient or unsuitable mucus, or when antisperm antibodies are present in the cervical mucus (Allen et al. - 1985). The variability among the reports of different authors concerning the success rate ranges from 0 up to 62%. (Allen et al. 1985). This is not surprising since pregnancy after IUI is a multifactor result dependent upon the ovulation evaluation, sperm quality, sperm preparation techniques, timing of insemination, number of inseminations and duration of therapy. In the present study, the experience of our Institute using this technique is summarized.
andrologia 22, No. 1 (1990)
Intrauterine Insemination
hCG was used to induce ovulation, inseminations were carried out 36 and 60 hours after hCG administration. Analysis of results was performed using Stundent t test.
Table 1: Sperm quality before and after washing. Values are mean fSEM Group 1 Group 2 Group 3
Results Sperm quality before and after washing in the subfertile sperm quality group and in the two other groups with good sperm quality are shown in Table 1. It is clear that the washing process caused a significant decrease in total sperm count, with a significant improvement in sperm motility (P
andrologia 22, (1): 29-33 (1990)
Institute for the Study of Fertility Serlin Maternity Hospital, Tel-Aviv Medical Centre and Sackler School of Medicine, Tel Aviv University, Tel-Avivhrael.
Intrauterine Insemination in Subfertile Couples. Intrauterine Insemination bei subfertilen Paaren H. Yavetz, A. Mosek, L. Yogev, G. Paz and Z. T. Homonnaj Key words: Intrauterine insemination, semen quality
Summary: 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 hMGhCG. One hundred and sixty seven inseminations were performed in 90 ovulatory cycles. Six pregnancies were recorded (14 Yo) :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 Yo). 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. Zusammenfassung: Mittels einer intrauterinen Insemination wurden 43 subfertile Frauen behandelt, wozu vorher die Spermatozoen gewaschen wurden. Unter diesen Paaren ergab sich in 7 Fallen ein Cervix-Faktor, in 17 Fallen wurde die Subfertilitat durch die Qualitat des Spermas verursacht und in 19 Fallen bestand eine sog. ,,unerklarte Infertilitat". Alle Frauen ovulierten: 9 spontan, 26, wenn sie mit Clomiphen behandelt wurden und 8, wenn eine hMG/hCG-Therapie durchgefuhrt wurde. In 90 Cyclen wurden 167 Inseminationen vorgenommen. Es resultierte eine Schwangerschaftsrate von 14 O/o (6 Graviditaten): hiervon entfielen 3 auf die Frauen mit Cervix-Faktor, 2 auf die schlechte Spermaqualitatsgruppe und 1 auf die Gruppe der unerklarten Infertilitat. Es wird hieraus die SchluBfolgerung gezogen, daB die intrauterine Insemination geeignet ist, um eine Schwangerschaft herbeizufuhren, wenn es sich um einen ungunstigen Cervix-Faktor handelt; dagegen ist der Wert dieser Methode zweifelhaft bei unerklarter Infertilitat und bei schlechter Spermaqualitat. Introduction
Intrauterineinsemination (IUI) has gained popularity in recent years, mainly since the increased expertise gained in sperm handling through in vitro fertilization programmes and the availability of artificial
media for washing sperm. There are at least four indications for the use of IUI: a) infertility due to hostile cervical mucus; b) subfertile sperm quality; c) immunologic infertility; and d) unexplained infertility (Moghissi - 1986). IUI has advantages over intravaginal of cervical insemina-
30
H. Yavetz. M.D. et al.
BBT recording, ultrasound measurement of the dominant follicle, cervical score determination and serum estradiol and progesterone measurements. The men’s fertility evaluation included medical history and physical examination, at least 2 semen analyses and hormonal profile determination. Medical treatment was given to 12 men in order to improve the semen quality: clomiphene citrate to 7 patients, mesterolone to 3 patients and hCG to 2 patients by protocols given elsewhere (Homonnai et al. - 1978). The couples were divided into 3 groups, according to the reason for infertility. Group 1comprised 7 couples in whom the women had viscid or no cervical mucus and negative PCT. The second group included 17 couples in whom the men had Materials and Methods oligoteratoasthenozoospermic semen. Forty-three infertile couples underwent The third group consisted of 19 couples in intrauterine inseminations. The mean age whom no obvious cause for infertility was found (unexplained infertility). of the women was 32.1years (range 23-42) In preparation for IUI, semen was and that of the men 34.7 (range 25-48). couple infertility period was 5.2 years obtained by masturbation and the quality was measured as published (Homonnai et (mean) with a range of 2-14. The women’s fertility evaluation includ- al. - 1980a). After liquification, the semen ed medical history and physical examina- was washed with lOml of Ham’s F-10 tion, recording of basal body temperature medium (Flow Laboratories, Scotland), (BBT), hormonal profile and at least two and centrifuged. The pellet was resuspendpostcoital tests. Hysterosalpingography ed in 0.3 ml of the Ham’s F-10 for insemi(HSG) and diagnostic laparoscopy were nation. This was carried out with the Makperformed as indicated. Twenty-fiveout of ler intrauterine cannula (Haifa, Israel), 43 women had normal hormonal blood while the woman lies in the dorsal litholevel tests. Eleven had elevated levels of tomy position. Insemination was scheprolactin and were given bromocriptine duled in the periovulatory period, accordtreatment. Nine patients were found to ing to the mode of monitoring. In spontaovulate spontaneouslyjudged by the BBT neous ovulators, insemination was done in chart and mid-luteal serum progesterone the periovulatory period as judged by the levels. Twenty-six women were treated last BBT chart. In cycles where clomiwith clomiphene citrate and 8 women with phene citrate was used to induce ovulahMG-hCG therapy to induce ovulation. tion, inseminations were performed HSG was performed in 35 women and according to preovulatory levels of serum diagnostic laparoscopy (in order to ex- estradiol (>200 pg/ml) and progesterone clude mechanical factor) was carried out in ( 1.5ng/ have mechanical problems. Monitoring of ovulation was carried out ml). One to four inseminations were perby at least two of the following methods: formed per cycle. In cases where hMG-
tions since it bypasses the cervix in cases of insufficient or unsuitable mucus, or when antisperm antibodies are present in the cervical mucus (Allen et al. - 1985). The variability among the reports of different authors concerning the success rate ranges from 0 up to 62%. (Allen et al. 1985). This is not surprising since pregnancy after IUI is a multifactor result dependent upon the ovulation evaluation, sperm quality, sperm preparation techniques, timing of insemination, number of inseminations and duration of therapy. In the present study, the experience of our Institute using this technique is summarized.
andrologia 22, No. 1 (1990)
Intrauterine Insemination
hCG was used to induce ovulation, inseminations were carried out 36 and 60 hours after hCG administration. Analysis of results was performed using Stundent t test.
Table 1: Sperm quality before and after washing. Values are mean fSEM Group 1 Group 2 Group 3
Results Sperm quality before and after washing in the subfertile sperm quality group and in the two other groups with good sperm quality are shown in Table 1. It is clear that the washing process caused a significant decrease in total sperm count, with a significant improvement in sperm motility (P
