Infertility is defined as the inability of the couple to achieve a successful pregnancy after 12 months of unprotected intercourse if the woman is under age 35, or after 6 months of unprotected intercourse if a female partner is greater than 35 years old. Infertility affects close to 15% of all couples trying to conceive a pregnancy. In 20% to 30% of such couples, infertility can be clearly identified as due to female causes, and in 20% to 30% of cases infertility can be clearly attributed to male-factor problems. The remaining cases are classified as “unexplained,” where no specific abnormalities can be identified in either of the partners.
ASSISTED REPRODUCTIVE THERAPIES
Intrauterine insemination may be performed if there are 5 to 10 million motile sperm in the ejaculate. However, success rates are not much better than with intercourse.
Intracytoplasmic sperm injection can be performed with nonmotile sperm, including surgically extracted testicular sperm.
Intrauterine insemination (IUI) is the most appropriate first step in couples who may have difficulties in accomplishing intercourse but the male partner has no difficulty in producing a semen sample by masturbation. It is also offered as the first step in the treatment of mild male-factor-related infertility where total motile sperm counts range from 5 to 10 million per ejaculate.
IUI involves introduction of spermatozoa suspended in culture media directly into the endometrial cavity. Preparation of the ejaculate for IUI involves removal of the seminal fluid, prostaglandins, and other cellular components from the ejaculate using either swim up, sperm wash, or Percoll gradient techniques. All spermatozoa separation techniques are aimed at removing the seminal fluid components that should not enter the uterine cavity and the extraction of spermatozoa with optimal motility for injection directly into the endometrial cavity closer to the fallopian tubes, where fertilization of the egg would be expected to occur. A comprehensive Cochran review found the pregnancy rates and clinical outcomes to be similar with the 3 sperm separation techniques.1 The choice of the technique for sperm preparation for IUI is guided largely by the local practice and the available equipment.
IUI should be carefully timed around the female partner’s ovulation. Ovulation can be tracked either by the urine luteinizing hormone (LH) tests at home, blood LH monitoring, or triggering ovulation with human chorionic gonadotropin (hCG) after appropriate follicular monitoring. IUI is usually performed within 24 hours after identification of the urine or blood LH surge or 36 hours after hCG injection.
The IUI nearly doubles the pregnancy rate compared to intercourse for couples with mild male-factor infertility. One randomized study in which intracervical insemination (ICI) was compared with IUI showed pregnancy rates of 3.1% per cycle for ICI versus 6.5% per cycle for IUI, respectively; however, comprehensive reviews of the available data do not support higher success rates for IUI procedures than for ICI....