Artificial Insemination as Related to the Female

Transcription

1 Artificial Insemination as Related to the Female Frances E. Shields, M.D. ARTIFICIAL INSEMINATION is a procedure of comparatively recent development for apparently it was not used in the human species previous to a century and a half ago. The first reliable record of its use in the human was in 17 when John Hunter was consulted by a man suffering from hypospadias. Hunter artificially inseminated the wife with the husband's semen and she became pregnant. Not untill, however, was there serious study and investigation of this procedure. In that year Marion Sims, then Consulting Surgeon of the Woman's Hospital in New York, performed a successful artificial insemination, the first to be reported in this country. In the last decade the procedure has been given more and more prominence, not only in medical literature but in lay periodicals. In consequence, requests for artificial insemination have been increasing rapidly from many couples suffering from infertility. Only in a small percentage of those requesting the procedure is it really indicated. INDICATIONS In general the indications for homologous insemination (or insemination with the husband's semen, to be referred to hereafter as A.I.H.) are: 1. Defective deposition of sperm in the vagina during coitus, as, for example, in cases of vaginismus or hypospadias.. Subnormal sperm count in the husband's specimen where use of a split ejaculate seems indicated. 3. Failure of sperm to survive the unfavorable environment of the wife's Presented November 3, 1, before the Section of Obstetrics and Gynecology, New York Academy of Medicine, N. Y. 71

2 7 SHIELDS [Fertility & Sterility vagina when, in Guttmacher's words, it seems wise to "give them a threeinch boost on a six-inch journey." 7 Indications for heterologous artificial insemination (or insemination with semen from a donor other than the husband, to be referred to hereafter as A.I.D.) are: 1. Sterility of the husband or such a pronounced necrospermia or oligospermia that pregnancy seems impossible.. Dysgenic factors in the husband which would make it unwise for him to reproduce. 3. Rh positive husband and a sensitized Rh negative wife. SELECTION OF DONORS In the case of A.I.D.'s, each donor should be selected to correspond racially and physically with the husband. His mental and physical status are of the greatest importance. His Wassermann must be negative, he must be free from disease, and his mental health must be unquestioned. He must have no family history of adverse characteristics of possible genetic significance.1 The semen specimen should meet the normal requirements of fertility. It is advantageous, but usually impractical, to choose as a donor a man who has children of his own and whose fertility has therefore been established. 10 His blood type should ideally be the same as that of the husband, and the Rh factor the same as that of the wife or, if this should be unknown for any reason or if it is doubtful, the donor's Rh should be negative. The identity of the donor and the husband and wife must always remain unknown to each other. An arbitrary limit of 100 siblings per donor has been set at one clinic in England for fear marriage betweensiblings not known to each other should assume dangerous proportions. 1 PROCEDURE Before inseminations are even planned, the physician should talk to both the husband and wife and be informed as fully as possible concerning their sincerity, their emotional stability, and their intellectual capacity. Usually the couple is fully aware of all the advantages of A.I.D.'s. The disadvantages should be stressed and the legal aspects explained. The procedure should never be undertaken if the couple wants it in the hope that a baby will cement an unstable marriage or if either of them is undecided about it.

3 Vol. 1, No. 3, 10] ARTIFICIAL INSEMINATION AND FEMALE 73 While it is true that among the most grateful people in the world are couples given babies by artificial insemination, there should be no semblance of mass production. The physician should be assured in each case that the procedure is justified. Before inseminations are undertaken, the status of the wife should be explored and her fertility established as far as possible. She is instructed to keep a basal temperature chart, the patency of her tubes is tested, and her Wassermann and Rh factor are determined. This would seem to be the minimum study necessary. Other more detailed investigations, such as B.M.R., endometrial biopsy, or vaginal smears, can be done if indicated. Some preliminary study of the wife has seemed in my experience and that of most other workers to save time, energy, and money for the patient, but Guttmacher suggests delaying the study until several inseminations have been done. As only a small percentage of women are sterile, he feels that in the majority of cases preliminary tests are unnecessary. The temperature graph gives much help in deciding the optimum days for inseminations. By studying 1 human ova, Rock and Hertig estimated that the postovulation phase fell within 1 and 1 (1 + ) days. At the time of ovulation the normal curve usually takes a characteristic drop and then rises, to remain elevated until just before the next period. A series of systematic observations has shown that artificial inseminations have a good chance of success if done on the day of the minimum temperature, the day preceding, or the day following. 10 Proper evaluation of the cervical mucus may also help to determine the day of ovulation. Ovulation mucus is clear and possesses great surface tensile strength. Clift, an English scientist, has devised an instrument called a menstruoscope or estroscope for measuring the How elasticity. It is not definitely known at what time after ejaculation sperm lose their capacity for fertilization. An arbitrary period of hours between inseminations has been adopted as a logical plan consistent with our present knowledge. From one to four inseminations during the calculated fertile period are usually done. An effort is made to calculate as accurately as possible from all evidence at hand the probable date of ovulation. The days for artificial insemination are spotted around this date. This will afford latitude for unpredictable error in the calculation of ovulation and insure a reasonable concentration of spermatozoa in the female generative tract (Figs. 1 and ).

4 7 SHIELDS [Fertility & Sterility TECHNIC OF INSEMINATION The semen specimen is collected by masturbation into a dry, clean, widemouthed glass receptacle and is kept at a temperature no higher than body temperature until used, which is usually within two hours, though time does not seem so important a factor. ~ 7 DAY OF CYCLE WnnBM~~Rm~~nU~UUUVUH~~~nM~~D ~ A ~ ~ 7 3 I ~ 7 DAY OF CYCLE n 1 13 M U M J Circle denotes coitus, X denotes day of menstrual flow. Upper graph illustrates typical ovulatory cycle. Drop followed by rise indicates approximate time of ovulation. Lower graph illustrates continued elevation of temperature when pregnancy occurs. FIGURE 1. The technic of the insemination is simple. The patient is placed on the examining table in the lithotomy position with the hips elevated. An unlubricated sterile speculum is inserted in the vagina and the cervix is visualized. The semen is aspirated into a dry, cool, glass syringe with an intravenous cannula attached. Without wiping or otherwise disturbing the cervix, the semen is spurted at the external os without any attempt being made to introduce any of it into the uterus. A piece of cotton is placed in

5 Vol. I, No. 3, 10] ARTIFICIAL INSEMINATION AND FEMALE 7 the folds of the buttocks to prevent soiling the patient's clothing, the speculum is withdrawn, and the patient is allowed to remain lying in this position with her legs extended or flexed as she desires for about twenty minutes. She then gets up and resumes her usual activities. She should have no cramps unless some of the semen has been injected into the uterus. Injection of part of the specimen into the uterus used to be an accepted procedure, f: 1 3 I 7 3 I DAY OF CYCLE 137 W»nDM~~n~~~~~n~~UVH~M~~~M~~» I DAY OF CYCLE 13 7 W»nnM~~n~~~~~n~~uvu~~~~~M~~» I ' 3 g' FIGURE. Records of two patients who became pregnant following A.I.D. Arrows indicate days on which A.I.D.'s were done. but disturbing uterine cramps usually followed, and occasionally an infection. This procedure has been generally abandoned now and, as a result, it has been found that the percentage of pregnancies has been getting better rather than worse. In cases where A.I.D. is being done because of oligospermia in the husband, a little of his semen is sometimes mixed with that of the donor in order to introduce the element of uncertainty. Psychologically, each of the partners usually responds favorably to such a suggestion.

6 7 SHIELDS [Fertility & Sterility RESULTS The number of months required for success varies. If A.I.D. is likely to succeed, it will usually do so very quickly. If there is no success within the first four months, the prognosis becomes less favorable. I should like to report briefly on a series of 3 consecutive patients who consulted me for fertility studies and A.I.D.'s. Of these 3 patients are still under treatment, discontinued within an average of three months because of opportunities to adopt babies or inability to continue for various reasons, usually associated with moving from the city during the war. Of the 0 remaining patients, 7 became pregnant and 3 were complete failures. These 3 were inseminated for an average of eighteen months each. Other doctors to whom I eventually referred them have unfortunately been equally unsuccessful. Of the 7 successful inseminations, the average age of the patients was 30. years, the average history of infertility. years. Successful inseminations occurred from the eighth day to the twenty-first day of the cycles, with the average falling between days 13 to 1. Eighteen patients became pregnant the first month, the second, the third, the fourth, 1 each in the sixth, seventh, ninth, tenth, eleventh, and nineteenth months. The over-all average of months required for success was 3.1 months; however, 7. per cent of the patients became pregnant in.0 months."' The trend of diminishing returns is also apparent in the published results of others. Guttmacher reported a series of 1 pregnancies following A.I.D.'s in which became pregnant the first month, the second, 1 the fourth, 3 the fifth and 1 after 3 months. Cary reported that out of successful inseminations 1 were successful after a single insemination. 3 The question always arises as to how long to continue inseminations before becoming discouraged. No case should be considered hopeless until an adequate period of trial has elapsed. One gynecologist thinks that three years with three inseminations a month is a fair trial period, but there are few patients who could stand the emotional and financial strain of such a long series of treatments. I feel that if A.I.D.'s do not succeed in months, the prognosis is not good, though every patient is told at the outset that she should plan to continue the inseminations for a year once they are Since reporting the above series there have been 3 more pregnancies following A.I.D., after 1 month and 1 after months of inseminations.

7 Vol. I, No. 3, 10] ARTIFICIAL INSEMINATION AND FEMALE 77 begun. In this way she does not become discouraged too soon and a further emotional hazard is not injected into the picture. In general A.I.H.'s are much less successful than A.I.D.'s. Wives of men who have normal seminal specimens yet who are unable to deposit the semen in the vagina constitute the most promising candidates for this treatment and a favorable prognosis is usually warranted. On the other hand, if a patient has been exposed to pregnancy over an acceptable trial period, there is not a good chance that she will become pregnant with A.I.H. Polak used to sum this up very tersely by saying, "If she could have, she would have." The use of a split ejaculate is helpful when the sperm count is low. Hotchkiss and MacLeod have found that if the specimen is collected in two parts, the first part of the ejaculate in one container and the remainder in another container, the first part will probably contain about 7 per cent of the sperm in the whole specimen. At the time of the insemination this first specimen should be introduced as described previously, and the second specimen should be placed high in the vagina to act as a buffer. We believe that in this way a larger number of sperm reach the cervix than would otherwise survive the acidity of the vagina. In a small series of 1 cases of A.I.H. I have had only pregnancies. In instances the husband had oligospermia. Split ejaculates were used and pregnancy followed 1 and series of inseminations respectively. I am not at all convinced that it would not have occurred without the inseminations. One patient accounted for the other successes. In this instance the husband had an abnormality of the penis which made normal intromission impossible. Pregnancy followed promptly after A.I.H., as should be expected where such a problem exists. Much has recently been written and said about hyaluronidase. This is an enzyme which is thought to be at least partly responsible for the penetrability of the follicle complex of the ovum and which is found, among other places, in semen. It is too early to say whether or not this substance will prove to be of practical help in our effort to overcome infertility. LEGAL ASPECTS It is uncertain what decision an individual court would hand down regarding the legitimacy of a child conceived by A.I.D. A Canadian court held that the procedure was adultery and the child illegitimate. English

8 7 SHIELDS [Fertility & Sterility courts have unanimously concurred in this opinion. The official report of a commission on artificial insemination appointed by the Archbishop of Canterbury has recently been published. All the members except the Dean of St. Paul's, Dr. W. R. Matthews, were agreed that artificial insemination with donated semen constitutes a breach of marriage. Dr. Matthews concluded his remarks with two general criticisms of the theological section of this report: l. It assumes a static view of nature and of man which was natural enough in the Middle Ages but perhaps is not so plausible now.. It takes a static view of society. Christians ought not to identify their religion with things as they are, even in the case of the family, which, like all human things, will change. One of the most heartening developments was in January, 1, when a jurist of the Supreme Court of New York State ruled in a case of A.I.D. that "The court has assumed for the purpose of its disposition that the plaintiff in this case was artificially inseminated with the consent and knowledge of the defendant. In the opinion of this court, assuming that the plaintiff was artificially inseminated, this child is not illegitimate." This is a court of general jurisdiction and is not to be confused with the Supreme Court of the United States. This decision, believed to be unprecedented in Anglo Saxon law, is to be regarded as of unusual significance. In view of all the facts at hand, it would perhaps still seem safer to urge the mother's husband to adopt the child legally. The signing of papers is a procedure on which opinions differ. Those who say, "Forget signed papers" seem to me to be doing a disservice to the patients. If the couple sign a simple consent for A.I.D., the wife certainly has some protection if in later years the husband should charge her with having an illegitimate child and be able to prove that he was sterile at the time the child was conceived. Such a paper might not hold much weight in a court of law, but it could hardly fail to impress a jury. The problem of the filling out of the birth certificate is a real one to those of us who do not like consciously to put our signature to an untruth. Many believe that in this instance a white lie is perfectly justified and the husband of the mother should be entered as the father of the child. In many cases the doctors who do the artificial inseminations feel that it is psychologically better for the patient to go to another doctor for her obstetric care, and for her and her husband to forget as soon and as completely as possible about

9 Vol. 1, No. 3, 10] ARTIFICIAL INSEMINATION AND FEMALE 7 the preliminary procedures. Under these circumstances, there is no problem because it has not yet become routine for an obstetrician to ask the patient, "Is this your husband's child?" He assumes that it is, and proceeds on that assumption. Before closing I should like to sketch briefly 3 cases of my own. A young couple living in a small town in a distant corner of the state had deferred pregnancy until six months after marriage. He was a professional man and had grown up in the community in which they were living. The day that they decided to discard contraceptives he contracted a severe case of mumps after which he was incurably sterile. Not wishing their friends to become aware of their misfortune, they sought advice in this city. A donor of the same mixed racial background as that of the husband was found, and the baby, conceived during one series of inseminations, was without doubt ''his father's child." Another patient whose husband's semen revealed complete azospermia came to the office four years after the birth of her baby conceived by A.I.D. I asked her why she had never planned to have another child and she told me that her husband was convinced that by some miracle this was his child. She knew that if she had more inseminations and became pregnant he would realize that neither baby was his. She had decided, and I believe wisely, not to disturb his conviction that he was a father. The husband of another patient was injured by a bullet wound during the war and complete paraplegia resulted. He was a brilliant young man and in spite of his handicap was able to drive a car, continue with his professional work, and live a full, useful life. They wanted and needed a baby to make their marriage complete, and since he was impotent because of his injury, they decided that A.I.D.'s were the solution to their problem. She became pregnant during the first series and because the baby resembled her husband and because none of their friends was aware of the extent of his paralysis, there was no question in anyone's mind as to the paternity of the child. In each of these cases the central figure is actually the husband. If there is no stronger urge in a mature married woman than to bear a child, it is equally true that there is no stronger urge in a mature married man than to father a child. In the past, adoption has been the obvious answer to the problem of sterility, but artificial insemination has opened a new door and it may well be that one day, under proper direction and control, it will be

10 0 SHIELDS [Fertility & Sterility available to more childless couples. We hear a great deal about the "planned baby." An A.I.D. baby is doubly planned and frequently doubly welcome. A successful artificial insemination is one of the most gratifying of all medical experiences. East, New York, N.Y. REFERENCES I. Barton, M., Walker, K., and Wiesner, B. P.: Brit. M. J. 1:0-3, 1.. British Medical Journal: :3-, Cary, W. H.: Am. J. Obst. & Gynec. :77-73, 1.. Clift, A. F.: Proc. Roy. Soc. Med. 3:1-, 1.. Greenhill, J. P., and Wright, J. F.: Am. Practitioner 1:7-1, 17.. Guttmacher, A. F.: J.A.M.A. 10:-, 1; Bull. New York Acad. Med. 1:73-1, Haman, J. 0.: California Med. :33-37, 1.. Rock, J., and Hertig, A. T.: Am. J. Obst. & Gynec. 7:33-3, 1.. Rohleder, H.: Test Tube Babies. New York, Panurge Press, Weisman, A. I.: West. J. Surg. 0:1-1, 1.