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Sperm objectives

Indications

Endometriosis

Results


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IUI

Intrauterine insemination, or IUI, is the process in which sperm are directly placed in the uterus in an attempt to achieve pregnancy.

In the normal situation a women's cervix is a barrier to entry by sperm. It estimated that with an excellent specimen in which a half billion sperm are deposited in the vagina, only about 1 million will get into the cervix, only 100,000 will enter the uterus at any one time, only 1000 will enter the tubes and perhaps 200 sperm will actually find the egg. [additional information]

The problem of achieving pregnancy from the viewpoint of sperm is both a qualitative and a quantitative problem. When sperm quality is diminished an even smaller number of sperm are likely to enter the uterus.

Sperm objectives with IUI

Our objective in utilizing intrauterine insemination is usually to place at least 10 million motile sperm into the uterine cavity. Prior to placing the sperm into the uterine cavity it must first be separated from the semen. Directly placing semen instead of just the sperm inside the uterus would likely cause pain and could make the patient ill. There are a number of methods used by laboratories to separate sperm from semen. Depending upon a particular individuals specimen some methods are likely to work better in terms of achieving pregnancy than others. The Male Fertility Assessment Laboratory utilizes a number of different methods that it can individualize to a man's sperm. In Infertility Solutions, we feel that intrauterine insemination is most effective when ovulation is being actively managed. Our approach is to perform the intrauterine insemination on the morning in which we cause ovulation to occur.

Indications for IUI

Intrauterine insemination is indicated for mild to moderate male factor infertility. If the sperm are sufficiently poor that a reasonable number of likely functional sperm cannot be obtained from the ejaculate, we believe that intrauterine insemination is a waste of time. Although pregnancies have been reported with this technology with very poor sperm it is possible that the occurrence of these pregnancies is as likely due to chance as to the application of this technology.

Another well established indication for intrauterine insemination is when the couple has an abnormal well timed post coital test. To compensate for an abnormal post coital test we feel that intrauterine insemination is the most cost and time efficient technology. One common therapy, the use of clomid or clomiphene citrate, causes a decrease in cervical mucous in about 1/3 of patients. Rather than try to diagnose this in a patient, it is much cheaper, quicker and less emotionally taxing to just use IUI whenever clomid is being used.

Endometriosis

Intrauterine insemination can also enhance the pregnancy rate per cycle in patients with normal sperm and endometriosis. One of the best accepted theories as to why endometriosis causes infertility is due to endometriosis causing increased macrophage activity in the abdomen. The macrophages destroy the sperm which enter the abdomen before the sperm can fertilize an egg. With more sperm in the abdomen, there is a higher probability that some sperm will reach the egg.

Results

Over the years our pregnancy rate with this therapy for male factor with patients selected as described above has varied between 12% and 25% percent per cycle depending on whether or not gonadotropins were used. (Note that the pregnancy rate is the delivery rate together with the miscarriage rate. The miscarriage rate is about 15% of clinical pregnancies.)

Our results are likely effected by choices we make with patients to pursue IUI as therapy.  The best way to evaluate the effectiveness of therapies is to perform randomized trials.  That is, a study is done that patients have to qualify for (e.g., having poor sperm and open tubes) and the particular treatment that the couple has is not chosen by any person but is randomized (e.g., chosen by a computer following a program unknown to the treating clinic).  The European Society of doctors treating infertility (ESHRE) reviewed all randomized studies (meeting their criteria) on treating male factor infertility with IUI and found a pregnancy rate of 7% per cycle when clomiphene was used and a 12% pregnancy rate per cycle when gonadotropins were used.  (Note again that this is the pregnancy rate and not the delivery rate.)

For more information on IUIs see "IUI and ICSI".