Artificial insemination is the insertion of treated semen into the female reproductive tract through non-coital methods. The prerequisite is that the fallopian tubes are usually confirmed after a test such as a hysterosalpingogram. With the development of sperm processing and freezing and ovulation promotion techniques, IUI has been improved clinically. Currently, the clinical pregnancy rate can reach 10-20%.
Indications for artificial insemination
1. Male partner factors.
(1) The male partner has anatomical abnormalities that prevent sperm from entering the vagina, such as severe hypospadias, retrograde ejaculation, etc.
(2) Psycho-neurological factors that make sexual life impossible, or premature ejaculation, non-ejaculation, etc.
(3) Immune factors in the male partner, with positive blood or semen anti-sperm antibodies.
(4) Moderate abnormal semen: such as sperm density <20< span="">′106/ml, normal morphology rate of 10-30%, severe semen volume reduction, long liquefaction time or non-liquefaction of semen, etc.
2. Female factors
(1) Abnormalities in the reproductive tract obstruct sperm operation, such as vaginal and cervical stenosis, vaginal spasm during sexual intercourse, etc.
(2) Cervical factors include abnormal cervical mucus, abnormal test after repeated sexual intercourse, etc.
(3) Immunological factors of the female partner, with positive anti-sperm antibodies.
3. Methods of artificial insemination for unexplained infertility
(1) Pericervical or intracervical insemination: 0.5-1.0ml of processed semen is slowly injected into the cervical canal, and the rest of the semen is placed in the anterior vaginal fornix for those who have difficulty in intrauterine insemination.
(2) Intrauterine insemination: It is a commonly used method with a high success rate. The sperm should be washed and optimized before IUI, and then 0.5-2.0 ml of semen should be injected into the uterine cavity through a catheter, and the patient should lie on his back for 10-15 minutes after the procedure.
IUI ovulation induction protocol
(1) Natural cycle: The woman has normal ovulation, ovulation and endometrial growth are monitored by ultrasound on day 10-12 of the menstrual cycle. When the dominant follicle reaches 18-20mm, blood E2 level reaches 270-300pg/ml and LH rises more than 2 times above the basal value, IUI can be considered after 12-36 hours.
(2) Clomiphene for ovulation: for patients with polycystic ovary syndrome, secondary low or normal gonadotropin amenorrhea, etc. Also HCG can be used to induce ovulation and IUI after 24-36 hours.
(3) Gonadotropin ovulation promotion: To improve pregnancy rate, gonadotropin ovulation promotion can be used to improve the quality of eggs in the cycle for ovulatory dysfunction in those who have not had a pregnancy for several cycles of clomiphene. Start with a low dose, i.e. 75 IU/day, and use maintenance, incremental or decremental doses depending on the patient’s response. Clomiphene combined with gonadotropins can also be used.
Analytical processing of semen specimens Fresh semen is obtained for processing 2 hours prior to IUI to obtain the required motile sperm density. The container containing the specimen is placed on a shaking bench and awaits liquefaction at 37C, which typically takes 5-30 minutes. Patients with positive antisperm antibodies are collected in 5 ml of HEPES-HTF fluid containing 50% serum for immediate examination and processing, which is required to reduce or remove prostaglandins, immunoreactive cells, antisperm antibodies, bacteria and debris from seminal plasma, reduce the viscosity of semen, promote sperm capacitation and improve sperm fertilization.
Frozen sperm provides fertility protection for some patients, including those who need radiotherapy or chemotherapy, and couples who have been separated for a long time. Frozen sperm can also be used for artificial insemination. Frozen sperm need to meet the following criteria after thawing: sperm density >20X106/ml, surviving sperm >20%, motility at level 2 or higher, sperm recovery after gradient centrifugation at 200,000 live sperm or higher, motility at level 2 or higher. Some degree of damage to sperm cell membranes may occur during the freezing process, but no difference in clinical pregnancy rates has been reported with frozen sperm compared with fresh semen for intrauterine insemination.
Complications of artificial insemination
(1) Ovarian hyperstimulation syndrome: The incidence is low during IUI, with a 1% incidence of moderate ovarian hyperstimulation. When using ovulation-promoting drugs, the drugs need to be adjusted appropriately according to the patient’s condition, especially in patients with polycystic ovary syndrome, and attention should be paid to the control of the starting dose. Specific prevention and treatment are described later in the section on in vitro fertilization and embryo transfer.
(2) Abnormal pregnancy outcome: when IUI is performed in ovulation-promoting cycles, the rate of multiple pregnancy is statistically about 20% and the rate of spontaneous abortion is 20%.
(3) Pelvic infections: relatively rare and require attention to asepsis during operation.
Artificial insemination by sperm donation
Donor insemination is a technique to insert sperm from a sperm donor into the female reproductive tract at the right time to achieve conception through non-coital methods. It is suitable for azoospermia caused by various reasons, especially non-obstructive azoospermia, testicular puncture without sperm, or the male partner has hereditary diseases such as mental illness, epilepsy, severe mental retardation, or the couple has severe maternal-infant blood group incompatibility due to special blood type that has failed to be treated. Because of the moral, legal and ethical issues involved, artificial insemination by sperm donation requires strict follow-up and management, and must be strictly enforced in accordance with the relevant national regulations.