Insemination - It Takes
Two to Tango!
Robert
J. Homm, M.D., FACOG©
Founder, Fertility & Endocrine Associates
Partner, Louisville Reproductive Center
http://www.ivfkentucky.com
Fertility & Endocrine Associates
4121 Dutchmans Lane #414
Louisville, KY 40207
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.
Robert 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, ARNP, recently opened Louisville Reproductive
Center, a full-scope fertility center and IVF laboratory.
© Copyright Robert J. Homm
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