A randomized comparison of intrauterine and intraperitoneal insemination in the treatment of infertility

Intrauterine pregnancy following low-dose gonadotropin ovulation induction and direct intraperitoneal insemination for severe cervical stenosis

BACKGROUND: We present a case of primary infertility related to extreme cervical stenosis, a subset of cervical factor infertility which accounts for approximately 5% of all clinical infertility referrals. CASE PRESENTATION: A 37 year-old nulligravida was successfully treated with ovulation induction via recombinant follicle stimulating hormone (FSH) and direct intraperitoneal insemination (IPI). Anticipating controlled ovarian hyperstimulation with in vitro fertilization/embryo transfer (IVF), the patient underwent hysteroscopy and cervical recanalization, but safe intrauterine access was not possible due to severe proximal cervical stricture. Hysterosalpingogram established bilateral tubal patency and confirmed an irregular cervical contour. Since the cervical canal could not be traversed, neither standard intrauterine insemination nor transcervical embryo transfer could be offered. Prepared spermatozoa were therefore placed intraperitoneally at both tubal fimbria under real-time transvaginal sonographic guidance using a 17 gage single-lumen IVF needle. Supplementary progesterone was administered as 200 mg/d lozenge (troche) plus 200 mg/d rectal suppository, maintained from the day following IPI to the 8th gestational week. A singleton intrauterine pregnancy was achieved after the second ovulation induction attempt. CONCLUSIONS: In this report, we outline the relevance of cervical factor infertility to reproductive medicine practice. Additionally, our andrology evaluation, ovulation induction approach, spermatozoa preparation, and insemination technique in such cases are described.

Intraperitoneal insemination in mammals: a review

This review focuses on factors associated with the development of intraperitoneal insemination in mammals. Findings to date indicate that fertility improves as the sperm cell concentration rises, but that the optimal sperm number differs in each species. Sperm washing before intraperitoneal insemination favours fertility. Peritoneal fluid shows a variable effect on spermatozoa, depending on the hormonal status of the female. The optimal time for insemination appears to be just prior to ovulation. The technique may be performed either through the abdominal or the vaginal wall. Verification of sperm deposition in the proximity of the ovaries improves fertility rates. Although associated with some risk of infection and an immune reaction against spermatozoa, the intraperitoneal technique rarely gives rise to severe anaphylactic shock, peritonitis, adhesion formation and the production of anti-sperm antibodies and these complications may be prevented by adequate sperm pretreatment and antibiotic therapy. The success of intraperitoneal insemination in humans, with results comparable with those of intrauterine insemination in the treatment of infertility, suggest the potential use of this technique in domestic mammals, especially in those in which intrauterine insemination poses practical difficulties. Some of the methods applied in human intraperitoneal insemination, such as confirming the position of the needle in the peritoneal cavity, and sperm pre-treatments might also improve results in domestic species. Conversely, the use of the animal model should help to develop some aspects of this technique in humans.

Efficacy of treatment for unexplained infertility

OBJECTIVE

To analyze the efficacy and cost-effectiveness of alternative treatments for unexplained infertility.

DESIGN

Retrospective analysis of 45 published reports.

SETTING

Clinical practices.

PATIENT(S)

Couples who met criteria for unexplained infertility. Women with Stage I or Stage II endometriosis were included.

INTERVENTION(S)

Observation; clomiphene citrate (CC); gonadotropins (hMG); IUI; and GIFT and IVF.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate.

RESULT(S)

Combined pregnancy rates per initiated cycle, adjusted for study quality, were as follows: no treatment = 1.3%-4.1%; IUI = 3.8%; CC = 5.6%; CC + IUI = 8.3%; hMG = 7.7%; hMG + IUI = 17.1%; IVF = 20.7%; GIFT = 27.0%. The estimated cost per pregnancy was $10,000 for CC + IUI, $17,000 for hMG + IUI, and $50,000 for IVF.

CONCLUSION(S)

Clomiphene citrate + IUI is a cost-effective treatment for unexplained infertility. If this treatment fails, hMG + IUI and assisted reproduction are efficacious therapeutic options.

An open multicenter study to compare the efficacy of intraperitoneal insemination and intrauterine insemination following multiple follicular development as treatment for unexplained infertility

PURPOSE

This multicenter study was carried out to compare the efficacy of intrauterine insemination (IUI) and intraperitoneal insemination (IPI) associated with multiple follicular development as treatment for unexplained infertility.

METHOD

A total of 205 couples completed the trial. Sixty-seven couples underwent treatment with IPI (group A) and 138 couples underwent treatment with IUI (group B).

RESULTS

Clinical pregnancy was obtained in 23 couples in group A (pregnancy rate: 34.3%) and in 36 couples in group B (pregnancy rate: 26.1%). No significant difference was observed between group A and group B. As for the evolution of pregnancies and the incidence of twin pregnancies, no significant difference was observed between the two groups.

CONCLUSIONS

Because IUI and IPI allow us to obtain same results and IPI is more invasive than IUI, the latter technique can be considered the method of choice and IPI should be used when IUI is difficult to perform, as in the presence of a tight cervical canal.

Corticosteroid treatment does not improve the results of intrauterine insemination in male subfertility caused by antisperm antibodies

AIM

To determine whether corticosteroid immunosuppression (CS) administered to the male partner together with intrauterine insemination (IUI) is preferable compared to IUI alone in treating male autoimmune subfertility.

MATERIALS AND METHODS

Thirty-six couples with proven male immunological subfertility were randomly assigned to begin CS + IUI (n = 18) or IUI (n = 18) treatment and progressed alternatively to receiving each treatment modality for three cycles unless pregnancy occurred. Each couple served as their own control. The administered corticosteroid was soluble prednisolone.

RESULTS

Five pregnancies were achieved with 77 cycles of CS + IUI and seven pregnancies with IUI alone. The pregnancy rates per cycle were 6.5% with CS + IUI and 9.21% with IUI, while the pregnancy rates per couple were 16.13% with CS + IUI and 21.2% with IUI alone. These rates do not differ to a statistically significant degree (P > 10%).

CONCLUSIONS

The addition of corticosteroid immunosuppression does not seem to significantly enhance the pregnancy rate in couples with male autoimmune subfertility treated with IUI as compared to the treatment with IUI alone. Considering the possible side-effects of corticosteroid intake, we conclude that IUI alone might be preferable to the combination of IUI with corticosteroid administration.