Comparison of the role of cervical and intrauterine insemination techniques on the incidence of multiple pregnancy after artificial insemination with donor sperm

Cervical insemination versus intra-uterine insemination of donor sperm for subfertility

BACKGROUND

Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples. Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus. Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates.

OBJECTIVES

To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm.

SEARCH STRATEGY

The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved.

SELECTION CRITERIA

Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available.

DATA COLLECTION AND ANALYSIS

Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed.

MAIN RESULTS

The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96).

AUTHORS' CONCLUSIONS

The findings of this systematic review support the use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.

Evaluation of the effect of a cervical cap device on sperm functional characteristics in vitro

Intracervical insemination continues to be employed for homologous and donor insemination in natural and stimulated cycles. Efficacy studies for potential fertility involve in vivo assessment; however, in vitro testing of particular sperm function(s) critically involved in fertilization is an important component of such evaluation. We report here on the in vitro evaluation of the effects of the silicone Veos cervical cap (Veos, London, UK) on sperm function. Donor semen was exposed to the Veos cervical cap or a sterile 15-cc centrifuge tube (control), or treated with the spermicide nonoxynol-9 (5 mg x ml(-1) in saline) for 4 h at 37 degrees C and 5% CO2 in water-saturated air. After exposure, motility characteristics, both in semen and in spermatozoa processed by standard swim-up procedure, cervical mucus penetration and sperm-zona pellucida interaction using the hemizona assay were assessed. Results indicated that exposure to the Veos cervical cap had no effect on either sperm motility characteristics or sperm-zona pellucida interaction. A small but significant difference was observed for cervical mucus penetration (P = 0.05); however, for both the control and treated groups, vanguard spermatozoa exceeded manufacturer's guidelines for a normal test, a penetration distance of > or = 30 mm. As expected, nonoxynol-9 was a potent inhibitor of sperm function. Lack of adverse effects on in vitro spermatozoa functional characteristics after exposure to the silicone Veos cervical cap supports its addition to the repertoire of fertility treatment modalities when cervical insemination is indicated.

[Can donor insemination be optimised?]

OBJECTIVE

To compare the different donor insemination technics.

MATERIAL AND METHOD

Analysis of the published studies about donor insemination which value the effectiveness of Intra Cervical Insemination (ICID) and Intra Uterine Insemination (IUID), the interest of ovulation induction, the possible complications, and the cost-effectiveness ratio.

RESULTS

The meta-analysis of the Cochrane data base (10 comparative studies IUID versus ICID, 2568 donor insemination cycles) lead to a pregnancy rate per cycle (PRC) 17.77% with IUID versus 7.68% with ICID. The odds ratio is 2.63 (CI from 1.85 to 3.73). With these PRC, the direct cost per evolutive pregnancy is 54,780 F with ICID and 25,675 F with IUID.

CONCLUSION

If it is possible to propose ICID to patient with an excellent regularity of ovulation. IUID with ovulation induction by gonadotropins is today the gold standard, and more especially as the law restrict the number of donor inseminations. Indeed, the IUID is two or three times more effective than ICID, consume the half of sperm straws, use a semen of moderate quality, there is no complication provided that the cycle is cancelled if there is more than two mature follicles and the cost-effectiveness ratio is greatly in favour with IUID.

Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis

OBJECTIVE

To determine whether artificial insemination with frozen donor sperm yielded a higher pregnancy rate per cycle by intracervical (ICI) or intrauterine (IUI) techniques. A meta-analysis was performed.

DATA IDENTIFICATION

A computerized MEDLINE search of the English-language literature on artificial insemination with donor sperm was performed and augmented by a review of meeting abstract books and references in published papers.

STUDY SELECTION

Only prospective randomized studies that reported monthly fecundity rates for IUI and ICI with frozen donor sperm were included.

DATA ANALYSIS

Seven studies were identified. The odds ratios (OR) and 95% confidence intervals (CI) were determined with use of the general estimating equation method for the three studies for which raw data could be obtained. For the remaining four studies, the OR and CI were assessed with use of the published summary data. A random-effects meta-analysis was then performed.

RESULT

Intrauterine insemination resulted in a significantly higher monthly fecundity rate with a common OR of 2.4 (CI 1.5-3.8).

CONCLUSION

On the basis of this meta-analysis of the seven prospective studies, IUI results in higher pregnancy rates than ICI for frozen donor insemination.