Cervical Intrauterine or Tubal Insemination What Is the Evidence by bigbro22

VIEWS: 22 PAGES: 5

									Cervical, Intrauterine or Tubal Insemination What Is the
Evidence?
P.-N. Barri, R. Tur, B. Coroleu and R. Buxaderas
Service of Reproductive Medicine, Department of Obstetrics and Gynecology, Institut Universitari
   Dexeus, Barcelona, Spain
The need for effective treatments of infertility has led to the acceptance of technical
procedures that, due to their high efficacy, have been incorporated into clinical practice
without the scientific benefit of previous welldesigned clinical trials. This is valid in
Reproductive Medicine for therapeutic strategies combining superovulation and
artificial insemination either with husband’s sperm (IUI) or with donor sperm (IAD).
Although uncontrolled clinical studies suggest a beneficial effect of combining
controlled ovarian hyperstimulation (COH) and artificial insemination, in order to draw
solid conclusions concerning the improve probability of pregnancy, new prospective
studies should be performed and comparisons among randomized clinical trials will be
of great value. GUZICK et al.,1999; COHLEN et al., 2001.
Traditionally, artificial insemination has been associated with the deposit of the sperm
in the endocervical canal (Cervical Artificial Insemination CAI), however new
techniques of sperm preparation have made it possible to concentrate only progressively
motile spermatozoa free of seminal plasma and to inject these into the uterine cavity
(Intrauterine Artificial Insemination IUI). Other studies have been conducted to evaluate
the improvement which can be obtained by using different ways and sites to deposit the
sperm preparation such as the fallopian tube (Fallopian tube sperm perfusion FSP) or
the peritoneal cavity (Direct Intraperitoneal Insemination DIPI). CROSIGNANI AND
WALTERS 1994; O’BRIEN and VANDEKERKHOVE 2001.
In order to find out whether different anatomical techniques of artificial insemination
could improve the results, we studied our own material together with the current
international scientific data available. We did not consider in the analysis the need to
combine controlled ovarian hyperstimulation with the artificial insemination because it
is generally accepted that clinical pregnancy rates are much higher when ovarian
stimulation protocols are used and that even in natural cycles intrauterine insemination
significantly increases the chances of pregnancy compared with timed intercourse. In
our opinion the only possible exception could be the use of cervical insemination for the
treatment of cases of sexual dysfunction and coital problems for the vaginal deposit of
sperm.
We will evaluate these different alternatives for performing artificial insemination
1) Cervical Insemination
2) Intraperitoneal Insemination
3) Intratubal Insemination
4) Intrauterine Insemination
Cervical Insemination
The first attempts at artificial insemination were carried out by placing the total volume
of fresh sperm ejaculated around the uterine cervix. However, due to the low pregnancy
rates achieved and to the possibility of modern sperm preparation techniques, cervical
insemination is currently very rarely performed and has progressively been replaced by
intrauterine insemination.
We think that there are two major indications for cervical insemination:
a) Cervical insemination
Cervical Insemination with total sperm without preparation which can be self injected in
the vagina in cases of sexual dysfunction and difficult vaginal sperm deposition. In
these circumstances, usually with normal ovulatory function and good sperm, we will


17 Barri
only have to teach the couple how to use home urinary LH kits and BBT charts to
identify the periovulatory period and to autoinject a fresh sample of husband’s sperm
into the vagina.
This is a simple and cheap technique which can be used for 3-4 cycles with a reasonably
acceptable pregnancy rate. We have applied this strategy in 34 cycles during the last
two years and we have achieved 4 pregnancies which means a 11.7% pregnancy rate per
cycle; this is not negligible considering the simplicity and low medicalisation involved
in this procedure.
b) Cervical donor insemination
When we started our donor insemination programme in the late 70s, cervical donor
insemination in unstimulated cycles was the rule. The last results that we obtained with
this protocol, when we performed 1540 cycles of cervical donor insemination during the
period 1991-1992 were 149 pregnancies (9.6% pregnancy per cycle). These cycles were
carried out in natural cycles without ovarian stimulation but when protocols of
controlled ovarian stimulation and intrauterine donor insemination had been applied, the
pregnancy rates achieved were higher, 212 pregnancies out of 1187 cycles performed in
the period 1993-1994 (17.8 % pregnancy per cycle).
For this reason we decided in 1993 to perform intrauterine insemination as a routine in
the donor insemination programme. During the period 1991-1997 we carried out 2259
cervical artificial donor insemination cycles and 247 pregnancies were obtained (11%
pregnancy rate per cycle) and 1390 intrauterine donor insemination cycles with 300
pregnancies achieved (21.7 % pregnancy rate per cycle) TABLE 1. We will discuss
later the advantages of such a policy in order to improve the results and the risks that we
are thereby increasing. WILLIAMS et al., 1995; TUR et al., 1997
Intraperitoneal Insemination
In the early nineties several studies were published suggesting a potential benefit of
placing the sperm closer to the oocytes via a direct transvaginal intraperitoneal
insemination (DIPI). The first prospective and randomized study with 124 infertile
couples treated either with direct intraperitoneal insemination (174 cycles and 8.6 %
pregnancy rate per cycle) or with intrauterine insemination (152 cycles and 12.5 %
pregnancy rate per cycle) failed to show significant differences in the pregnancy rates
between both techniques. HOVATTA et al., 1990. Similar results were published some
years later in the ESHRE multicentre trial on the treatment of male subfertility with 499
treatment cycles randomly distributed in different therapeutical options. In this study,
after 70 cycles of intraperitoneal insemination an overall pregnancy rate per cycle of 9.6
% was achieved. These figures are somewhat lower than those previously reported with
different indications and in which higher pregnancy rates were obtained in cases of
unexplained infertility (23 %) whereas when there was an abnormal male factor the
pregnancy rates dropped (17 %) CROSIGNANI et al., 1991.
A more recent, randomized, cross-over study in which every treatment cycle was
followed by a non-treatment cycle, reported a significant reduction in the pregnancy rate
obtained after a cycle of intraperitoneal insemination (DIPI) 16% versus 24% after
intrauterine insemination (IUI) (p=0,018). TIEMESSEN et al., 1997. Considering this
lack of improvement together with the fact that DIPI is a more painful procedure which
requires more staff involvement and cost, it can be concluded that DIPI does not offer
better chances of pregnancy than IUI in superovulated. cycles. The same lack of
improvement has been reported in an Italian open multicentre study which compares
DIPI and IUI in cases of unexplained infertility. AJOSSA et al., 1997.
Intratubal Insemination



                                            2
Sperm perfusion was applied for the first time by KAHN et al., in 1992 whe the authors
published the first results with a modified technique which involves the combination of
ovarian stimulation and the intrauterine insemination of 4 ml of sperm suspension which
will pass through the Fallopian tubes and will reach the Dougla’s pouch.
This technique show promising initial results and these sperm perfusion protocols (FSP)
were applied in other indications such as donor insemination with good results (27.9 %
pregnancy rate per cycle) KAHN et al., 1992, although ectopic pregnancies have been
reported after these procedures BALASCH et al., 1992. Several prospective,
randomized studies have been published with contradictory results, better pregnancy
rates for IUI (HURD et al., 1993) or for FSP (KAHN et al., 1993).
More recent studies have insisted on the improvement that can be achieved with tubal
perfusion with either husband’s or donor sperm. Again, results are still contradictory
and some studies present pregnancy rates with FSP that are twice as high as with IUI
(FANCIN et al., 1995) and others fail to report any benefit (EL SADEK et al.,
1998).Finally a new article including a prospective comparative study between
Fallopian sperm perfusion and intrauterine insemination and a metaanalysis of the
literature showed that only patients with unexplained infertility benefit from the
application of a cycle of FSP instaed of IUI. TROUT and KEMMAN 1999.
Intrauterine Insemination
Intrauterine insemination (IUI) in natural cycle or under controlled ovarian
hyperstimulation has been used extensively to treat different forms of infertility. So far,
very few prospective studies are available to find out a possible benefit of treating
infertile couples with this procedure. We know that in cases of male subfertility,
intrauterine insemination offers a clear benefit over timed intercourse both in natural
cycles or in cycles with ovarian stimulation. COHLEN et al., 2001.
Other studies have shown that the combination of induction of superovulation and
intrauterine insemination (IUI) is three times as likely to result in pregnancy as is
intracervical insemination and twice as likely to result in pregnancy as is treatment with
either superovulation and intracervical insemination or intrauterine insemination alone.
GUZICK et al., 1999.
Nevertheless, several questions should be answered in relation with the indication for
the treatment and the minimal sperm quality required to accept a couple in this
programme. In this sense, it is interesting to note that cases with unexplained infertility
or with moderate male infertility with an average total motile sperm count of more than
10 million spermatozoa, have better pregnancy rates than cases with other pathologies
such as endometriosis or mild pelvic disease. VAN VOORHIS et al., 2001; SINGH et
al., 2001.
Another crucial factor to be taken into consideration is the application of intrauterine
insemination to improve the results of classical cervical donor insemination. In our
experience, we have significantly increased the pregnancy rates as other groups have
done, O´BRIEN and VANDEKERCKHOVE 2001; WAINER and FAGNANI 2001, but
we have also increased the risk of multiple pregnancy. TUR et al., 1997.
It is very important to identify the risk factors associated with multiple pregnancies and
by knowing them establish soft protocols of ovarian hyperstimulation controlled with
careful monitoring and cancelling those cycles with excessive follicular recruitment and
very high estradiol levels. In our experience IUI cycles under superovulation with more
than 3-4 follicles and estradiol values above 800 pg/ml should be cancelled because of
the increased risk of multiple pregnancy. TUR et al., (in press)TABLE 2. We are
convinced that by following this policy we can treat our infertile couples efficiently,



                                            3
controlling an important factor such as the costs of these treatments, VAN VOORHIS et
al., 1999; PHILIPS et al., 2000 and minimizing their side effects.
Bibliographic References
GUZIK D. S., CARSON S.A., COUTIFARIS C., OVERSTREET J.W., FACTOR-
LITVAK P., STEINKAMPF M.P. et al. Efficacy of superovulation and intrauterine
insemination in the treatment of infertility N. ENG. J. MED.340:177-83.1999.
COHLEN B.J., VANDEKERCKHOVE P., TE VELDE E.R., HABBEMA J.D.F. Timed intercourse
versus intrauterine insemination with or without ovarian hyperstimulation for subfertility in men
Cochrane Review. The Cochrane Library Issue 1.2001.
CROSIGNANI P.G., WALTERS D.E. Clinical pregnancy and male subfertility;the
ESHRE multicentre trial on the treatment of male subfertility. HUM.REPROD.9-
6:1112-8.1994.
O´BRIEN P., VANDEKERKHOVE P. Intauterine versus cervical insemination of donor sperm for
subfertility. Cochrane Review. The Cochrane Library Issue 1. 2001.
WILLIAMS D., MOLEY K., CHOLEVA C., ODEM R., WILLAND J., GAST M Does
intrauterine insemination offer an advantage to cervical cap insemination in a donor
insemination program? FERTIL. STERIL.63-2:295-8.1995.
TUR R., BUXADERAS CH., MARTINEZ F., BUSQUETS A., COROLEU B., BARRI
P.N. Comparison of the role of cervical and intrauterine insemination techniques on the
incidence of multiple pregnancy after artificial insemination with donor sperm. J.
ASSIST. REPROD. GEN. 14-5:250-3.1997.
HOVATTA O., KURUNMAKI H., TIITINEN A., LAHTEENMAKI P., KOSKIMIES
A. Direct intraperitneal or intrauterine insemination and superovulation in infertility
treatment: a randomized study FERTIL. STERIL 54-2:339-41.1990.
CROSIGNANI P.G., RAGNI G., LOMBROSO FINZI G.C., DE LAURETIS L.,
OLIVARES M.D., PEROTTI L. Intraperitoneal insemination in the treatment of male
and unexplained infertility. FERTIL. STERIL. 55-2:333-7.1991.
TIEMESSEN C.H.J., BOTS R.S.G.M., PEETERS M.F., EVERS J.L.H. Direct
intraperitoneal insemination compared to intrauterine insemination in superovulated
cycles:A randomized cross-over study. GYNECOL. OBSTET. INVEST. 44:149-
52.1997.
AJOSSA S., MELIS G.B., CIANCI A., COCCIA M.E., FULGHESU A.M.,
GIUFFRIDA G., GUERRIERO S., LANZONE A., SCARSELLI G. An open
multicenter study to compare the efficacy of intraperitoneal insemination and
intrauterine insemination following multiple follicular development as treatment for
unexplained infertility. J. ASSIST. REPROD. GENET. 14-1:15-20.1997.
KAHN J.A., VON DURING V., SUNDE A., SORDAL T., MOLNE K. Fallopian
sperm perfusion. First clinical experience HUM. REPROD. 7-Suppl 1:19-24.1992.
KAHN J.A., VON DURING V., SUNDE A., MOLNE K. Fallopian sperm perfusion
used in a donor insemination programme. HUM. REPROD. 7-6:806-12.1992.
BALASCH J., BALLESCA J.L., FABREGUES F., PUERTO B., CASAMITJANA R.,
VANRELL J.A. Transvaginal intratubal insemination, ectopic pregnancy and treatment
by single-dose parenteral methotrexate. HUM. REPROD. 7-10:1457-0.1992.
KAHN J.A., SUNDE A., KOSKEMIES A., VON DURING V., SORDAL T.,
CHRISTENSEN F., MOLNE K.
Fallopian tube sperm perfusion (FSP) versus intrauterine insemination(IUI) in the
treatment of unexplained infertility: a prospective randomized study. HUM. REPROD.
8-6:890-4.1993.
HURD W.W., RANDOLPH JR J.F., ANSBACHER R., MENGE A.C., OHL D.A.,
BROWN A.N., Comparison of intracervical, intrauterine, and intratubal techniques for
donor insemination FERTIL. STERIL.59-2:339-42.1993.


                                               4
EL SADEK M.M., AMER M.K., ABDEL-MALAK M.K. Questioning the efficacy of
Fallopian tube sperm perfusion. HUM. REPROD. 13-11:3053-6.1998.
FANCIN R., OLIVENNES F., RIGHINI C., HAZOUT A., SCHWAB B., FRYDMAN
R. A new system for Fallopian tube sperm perfusion leads to pregnancy rates twice as
high as standard intrauterine insemination. FERTIL. STERIL. 64-3:505-10.1995
TROUT S., KEMMAN E. Fallopian sperm perfusion versus intrauterine insemination: a
randomized controlled trial and mettanalysis of the literature. FERTIL.STERIL. 71-
5:881-5.1999.
VAN VOORHIS B.J., BARNETT M., SPARKS A.E.T., SYROP C.H., ROSENTHAL
G.,DAWSON J. Effect of the toal sperm count on the efficacy and cost-effectiveness of
intrauterine insemination and in vitro fertilization FERTIL. STERIL. 75-4: 661-8. 2001
SINGH M., GOLDBERG J., FALCONE T., NELSON D., PASQUALOTTO E.,
ATTARAN M., AGARWAL A. Superovulation and intrauterine insemination in cases
of treated mild pelvic disease J. ASSIST. REPROD. GENET. 18-1:26-9.2001
WAINER R., FAGNANI F. Peut-on optimiser l´insemination avec donneur?
GYNECOL.OBSTET.FERTIL. 29:93-9. 2001
VAN VOORHIS B.J., STOVALL D., ALLEN B., SYROP C.H. Cost-effective
treatment of the infertile couple FERTIL. STERIL. 70-6: 995-1005. 2001
PHILIPPS Z., BARRAZA-LLORENS M., POSNETT J. Evaluation of the relative cost-
effectiveness of treatments for infertility in the UK HUM. REPROD. 15-1;95-106. 2001
TUR R., BARRI P.N., COROLEU B., BUXADERAS R., MARTֽNEZ F., BALASCH
J. Risk factors for high-order multiple implantation after ovarian stimulation with
gonadotropins: evidence from a large series of 1878 consecutive pregnancies in a single
center” HUM. REPROD. 2001 (In press)

Table I. Artificial donor insemination (AID). results (1991-1997)
Table II. Observed numbers of cycles with low-order and high-order pregnancy and
predicted probability of high-order pregnancy according to multivariate ordinal logistic
regression analysis*




                                            5

								
To top