Infertility refers to an inability to conceive after having regular unprotected sex. Infertility can also refer to the biological inability of an individual to contribute to conception, or to a female who cannot carry a pregnancy to full term
Artificial insemination for infertility, intrauterine insemination – IUI
Intrauterine insemination is also called IUI or artificial insemination.
The IUI procedure can be an effective treatment for some causes of infertility in women under age 41
- Tubal blockage or severe tubal damage
- Ovarian failure (menopause)
- Severe male factor infertility
- Severe endometriosis
Artificial insemination should not be used in women with blocked fallopian tubes. The tubes are often checked out with an x-ray test called a hysterosalpingogram.
Female age is a significant factor with IUI. Intrauterine insemination has very little chance of working in women over 40 years old. IUI has also been shown to have a reduced success rate in younger women with a significantly elevated day 3 FSH level, or other indications of significantly reduced ovarian reserve.
If the sperm count, motility and morphology scores are quite low, intrauterine insemination is unlikely to work.
- Details on IUI success rates according to the sperm numbers
- With significant male factor issues, IVF with ICSI is indicated and has high success rates
It is also used for couples affected by mild endometriosis, problems with ovulation, mild male factor infertility and cervical factor infertility.
How is insemination performed? What is the process for artificial insemination in humans?
- The woman usually is given medications to stimulate development of multiple eggs and insemination is timed to coincide with ovulation – release of the eggs.
- A semen specimen is either produced at home or in the office by masturbation after 2-5 days of abstinence from ejaculation.
- The semen is “washed” in the laboratory (called sperm processing or sperm washing). The sperm is separated from the other components of the semen and concentrated in a small volume. Various media and techniques can be used for the washing and separation. Sperm processing takes about 30-60 minutes.
- A speculum is placed in the vagina and the cervical area is gently cleaned.
The intrauterine insemination procedure, if done properly, should seem similar to a pap smear for the woman. There should be little or no discomfort.
Most clinics offer for the woman to remain lying down for a few minutes after the procedure, although it has not been shown to improve success. The sperm has been put above the vagina and cervix – it will not leak out when you stand up.
For a couple with unexplained infertility, female age under 35, trying for 2 years, and normal sperm – we would generally expect about:
- 10% chance per month of getting pregnant and having a baby with artificial insemination and Clomid for up to 3 cycles (lower success after 3 attempts)
- 15% chance per month of getting pregnant and having a baby with injectable FSH medication and IUI for up to 3 cycles
- 55% chance of conceiving and having a baby with 1 IVF cycle (at our center – success rates vary between clinics)
Chances for success in women over 35 drops off, and for women over 40 them are much lower.
How many inseminations to try before doing IVF?
- If the female is age 40 or older, or ovarian reserve low, consider IVF earlier
- In vitro fertilization has a significantly higher success rate as compared to IUIMore on when to move from IUIs to IVF
Any insemination should be carefully timed to occur at or a little before the time of ovulation. We know that in some couples, sperm can remain viable in the female reproductive tract and result in fertilization of an egg for five days (after having sex).
In Vitro Fertilization, IVF – the Process and Procedures
What is in vitro fertilization – IVF?
The IVF process involves:
- Stimulating multiple follicles and eggs to develop
- Egg retrieval to get the eggs
- Fertilizing the eggs in the laboratory
- Embryo transfer to the uterus
- Hundreds of thousands of children are born every year after IVF treatments
Who should be treated with in vitro fertilization?
IVF can be used as an effective treatment for infertility of all causes except for women with infertility caused by an anatomic problem with the uterus, such as severe intrauterine adhesions.
It is generally used in couples who have failed to conceive after at least one year of trying who also have one or more of the following:
- Blocked fallopian tubes or pelvic adhesions with distorted pelvic anatomy. Women that have had tubal ligation and are considering tubal reversal surgery as well as men that are considering vasectomy reversal surgery might also consider IVF.
- Male factor infertility low sperm count or low motility. ICSI is an IVF procedure that can fertilize eggs even with poor sperm quality.
- Failed 2-4 cycles of ovarian stimulation with intrauterine insemination
- Reduced ovarian reserve, which means lower quantity (and sometimes quantity) of eggs. Severe endometriosis
- Unexplained infertility when inseminations have failed. Unexplained infertility means standard fertility tests have not found the cause of the fertility issue.
How does IVF improve fertility?
In vitro fertilization increases the efficiency of human reproduction, which is often not very efficient naturally.
- Essentially, it is a numbers game that worsens as the female partner ages
- With IVF we remove multiple eggs – and after careful culture for 3-5 days of the eggs that fertilize, there transfer one or more of the “prettiest” embryos back to the uterus.
- Any remaining embryos can be frozen for future use by the couple
In a sense, there compress many months of “natural” attempts into one menstrual cycle. By transferring the fertilized embryos directly to the uterine cavity, fertility is improved for many couples that have sperm issues fertilization defects, or issues on the female side related to egg pickup from the ovary, or tubal transport of the embryo to the uterus.
Implantation rates are considered by fertility doctors when talking with couples about their chances for IVF success rates and multiple births.
Ovulation Problems and Infertility: Treatment of ovulation problems with Clomid and other fertility drugs
What is induction of ovulation?
Ovulation induction involves the use of medication to stimulate development of one or more mature follicles where eggs develop in the ovaries of women who have anovulation and infertility. These women do not regularly develop mature follicles without help from ovulation enhancing drugs.
Some of the women with anovulation have a condition known as PCOS or polycystic ovarian syndrome. These women often have irregular menstrual cycles, increased body hair, and infertility.
How is induction of ovulation performed?
There are four basic types of medication that are used to induce ovulation. Treatment with these drugs has the potential to result in pregnancy if the woman has good quality eggs remaining in her ovaries, and if other causes of infertility are not present.
For women with ovarian failure or extremely very poor quality eggs there are not currently any drug available to allow a reasonable chance of conception with any type of ovarian stimulation.
The five major types of ovulation drug therapy are Available:
- Femara or letrozole and other aromatase inhibitors
- Injectable gonadotropins, injectable FSH hormone products
- The GnRH pump
Success rates for induction of ovulation vary considerably and depend on the age of the woman, the type of medication used, whether there are other infertility factors present in the couple, and other factors.
Male Infertility Treatment – How to Get Pregnant with Sperm Problems
ICSI in progress, ICSI needle is inside egg, sperm is being injected, holding pipette at far left
Treatment for sperm problems
Men with low sperm counts or low motility often ask for treatment to correct the defect. Unfortunately, this is not often possible. Many cases of sperm abnormalities are genetic in origin.
Since there is currently no way to correct such genetic defects, we end up working with the couple in ways that will (hopefully) increase their reproductive efficiency. This usually involves either intrauterine insemination, or in vitro fertilization (more below).
If the man has a hormonal deficiency, it might be treatable with medications. These are rare cases.
A varicocele is an abnormal tortuosity and dilation of veins of panpiniform plexus within the spermatic cord. If there is a varicocele, it can be surgically treated – which might help fertility in some cases.
However, well controlled studies of surgery vs. no surgery have failed to consistently demonstrate increased pregnancy rates with surgical correction. Some studies have shown better pregnancy rates after surgery, but other studies have shown lower pregnancy rates following surgery.
Clomiphene citrate (Clomid, Serophene) for the infertile male
Some men with relatively mild sperm abnormalities have been treated with clomiphene citrate (tablets) in an attempt to improve the semen. According to published medical literature, Clomid for the male sometimes can improve the sperm count or motility. However, well-controlled medical studies have shown no increase in pregnancy rates.
Intrauterine insemination and in vitro fertilization
Mild to moderately low sperm counts and/or motility
Inseminations for about 3 months Then consider IVF with ICSI if not pregnant
Severely low counts and/or motility:
IVF with ICSI
Infertility due to mild to moderate sperm abnormalities can sometimes be successfully treated with ovarian stimulation combined with IUI – intrauterine insemination.
Success rates with insemination (IUI) for low sperm numbers
Moderate degrees of sperm abnormalities can also be treated with IUI; however, more often they will require in vitro fertilization in order to conceive.
Severe sperm abnormalities require either in vitro fertilization with intracytoplasmic sperm injection (ICSI) or donor sperm insemination, whichever the couple prefers.