THE INDICATIONS FOR, advantages and disadvantages of insemination have

Transcription

1 Fertility as Evaluated by Artificial Insemination Sheldon Payne, M.D., and Robert F. Skeels, M.D. THE INDICATIONS FOR, advantages and disadvantages of insemination have been reviewed and presented before this group by several authors 5 8 and will not be discussed in this paper. We are primarily concerned with the unique advantages offered to the student of infertility by couples where the wife is presumably fertile, and the husband subfertile or hopelessly sterile, and both are so anxious to have children (conscience permitting) that they are willing to submit to any reasonable experimentation. Accordingly, we would like to present data from our private practice relative to the following three questions: 1. Is the basal temperature (BT) record of value in determining optimal timing for intercourse (insemination)? 2. Can minimal standards for male fertility be established by comparing results of donor (AID) and homologous (AIR) inseminations using various grades of semen quality? 3. Is the "split specimen" technic any advantage when semen specimens are consistently below par? Although BT records are generally employed, opinions differ concerning their interpretations and usefulness. Farris found BT only 45 per cent satisfactory for determining ovulation in 27 women studied, and in his series pregnancies occurred from a single insemination as many as five days before or as long as three days after the rise in temperature. The Sieglers conclude that BT is of definite but very limited value in infertility studies From The Shelton Clinic, Los Angeles, California. Presented at the First World Congress on Fertility and Sterility, New York City, May 29,

2 Vol. 5, No.1, 1954 AI AND FERTILITY 33 and of the 8 conceptions reported from single AID 1 occurred 3 days before the rise in temperature; 2, 2 days before the rise; 1, at the low; 2, at the rise; and 1 on the first day, and 1 on the second day of the high phase of the graph. BT records are most helpful to Hamen and of 400 records of pregnant women reviewed, the patient had coitus either the day before the drop, the day of the drop, or the morning of the rise in temperature in all but 3 cases. DONOR INSEMINATIONS (AID) Sixty-seven presumably fertile women married to hopelessly sterile husbands and anxious to have children by AID were instructed to keep BT TABLE 1. Results in 336 Donor Inseminations Timed to Basal Temperature Basal temperature Total Number of Percentage timing inseminations pregnancies success Days before ovulation - 5 or earlier (AB) (C) 15.2 Day of ovulation (ABD) 15.2 Days after ovulation (C) (D) or later Anovulatory cycles Timing unknown TOTALS Four patients, A, B, C, and D, became pregnant on cycles when 2 inseminations were done and a half "credit" is given for each insemination. records for several cycles and studies were made of vaginal smears and cervical mucus. AID's were done three hundred and thirty-six times at various times throughout the menstrual cycles, usually 1 and not more than 2 to a cycle; and the results recorded (see Table 1). Donors were all healthy, years of age, usually married and with families of their own. Semen employed was of good or superior quality. Pregnancies were achieved in 38 patients (57 per cent) during the period of observation; of these, records are complete in 31. There are 27 preg-

3 34 PAYNE & SKEELS Fertility & Sterility nancies by single AID with known timing to BT and 4 patients-designated A, B, C, and D-are pregnant on cycles when 2 AID's were done. In each instance the repeat AID was performed 2 days following the initial one and on the days indicated in Table l. Since we could not reasonably attribute the conception more to one insemination than another, a half "credit" is given to each insemination when 2 were administered in a successful cycle. Fifteen (48.4 per cent) of the 31 women pregnant with known timing to BT conceived when inseminated on the day of the low point before the sustained temperature rise. This we have empirically designated the day of ovulation. Ten pregnancies (32.3 per cent) occurred when insemination was done the day of the temperature rise (usually in the morning). The percentage of success the day before ovulation also was comparatively good. However, of the conceptions with known timing, no pregnancies occurred TABLE 2. Inseminations required Patients pregnant Percent pregnant Results with 38 Patients Pregnant by Donor Insemination or more 2 5 if inseminations were done sooner than 2 days before ovulation or later than 2 days after the temperature rise. Those who conceived, usually did so readily when timing was satisfactory. Twenty patients (52.6 per cent) required 1-3 AID's, 16 (42.0 per cent) 4-9, and only 2 patients (5.3 per cent) required 10 or more inseminations (Table 2). In our experience BT is the most valuable criteria for optimal timing of intercourse (insemination). Vaginal smear studies are time-consuming, and the changing patterns are too gradual to be of practical value. Examination of cervical mucus, particularly the fernlike crystallization phenomenon, is helpful for determining receptivity of the cervical mucus to spermatozoa, as Campos da Paz and Roland have reported. The ease with which the test can be performed should lend it to general employment. The fernlike phenomenon normally appears throughout the estrin phase, and usually, when compared to BT graphs, does not begin to disappear until the third day or later after the low point preceding the sustained rise. The end point, therefore, in our experience is too indefinite for practical use in determining optimal timing for inseminations. We can confirm the thesis of Cohen et al. that Spinnebarkeit (thread formation) of cervical mucus is usually maximal just preceding or coincid-

4 Vol. 5, No.1, 1954 AI AND FERTILITY 35 ing with the thermal shift in BT. Many physicians will find this a simple test to augment BT records. Occasionally we have noted a patient pregnant with a Hat BT graph or with a biphasic shift and no intercourse charted close to the supposed ovulation time. However, if the BT is biphasic and charts properly kept, the thermal shift generally is the most valuable guide for optimal timing of intercourse and/or inseminations. HOMOLOGOUS ARTIFICIAL INSEMINATIONS (AIH) It has been our experience that semen quality varies widely from time to time in a given individual, and that a random specimen from a husband does not necessarily indicate the level at which conception occurred. The TABLE 3. Comparison of AID and AIH Procedures Number of Number of Number of patients inseminations pregnancies AID AIR TOTALS Of the 159 patients receiving AIR an additional 26 became pregnant, but conception could not be reasonably attributed to the AIR procedure. AIH technic seemed to offer a tool by which minimum standards of male fertility might be further evaluated. A group of 159 couples were studied where the wife was considered fertile, except at times because of the presence of hostile cervical secretions, TABLE 4. Incidence of AIH* Conceptions Relative to Sperm Counts Sperm count Number of Numberaf Percentage of Percentage of millions/ cc. inseminations conceptions conceptions per AIR total conceptions and up TOTALS * AIR all timed to biphasic BT curves and all done between days -2 to +2.

5 36 PAYNE & SKEELS Fertility & Sterility and where homologous inseminations (AIH) were employed, using semen of various grades of quality. Fifty-six women (35.2 per cent) conceived. Records were studied critically and only the 382 inseminations performed between days -2 and +2, relative to the low point before the sustained temperature rise which was considered the wives' fertile period, are included (see Tables 4 and 5). Thirty pregnancies could be attributed with reasonable confidence to the AIH procedure and with known semen quality. Twenty-five per cent of the pregnancies occurred when the sperm count was between 20 and 60 million with a median of 85 million. Also twentyfive per cent of the conceptions occurred with initial motility below 65 per cent and the median was 75 per cent. No pregnancies occurred with sperm TABLE 5. Incidence of AIH * Conceptions Relative to Degree of Motility Percentage Number of Number of Percentage of Percentage of motility inseminations conceptions conceptions per AIH total conceptions HI TOTALS * AIH all timed to biphasic BT curves and all done between days -2 to +2. counts below 20 million per cc. and there was no success when the initial motility was less than 20 per cent. * MacLeod has recently reported a prodigious statistical work in an attempt to establish normal semen standards, using looo fertile husbands. It is interesting to note that our data fairly closely correspond to his, although we cannot claim any great statistical significance for our study (Figs. 1 and 2). MacLeod's first quartiles fell below 54 million and 50 per cent initial motility. The notable difference between our data and those of MacLeod * All semen analyses were done by Mrs. Hazel Kirsch, chief technician for The Shelton Clinic, thus lending consistency to this data. Motility was estimated by examination of several highpower fields of a simple, wet cover-slip preparation.

6 Vol. 5, No.1, 1954 AI AND FERTILITY % PREGNANT ZO~ O. BELOW SO SO COUNT PER CC IN MILtlONS I Q. Fig. 1. Sperm counts and successful AIR. 190 I I Qz is that we have not been fortunate enough to produce any conceptions with counts below 20 million and motility below 20 per cent. The high failure rate of AIR as compared to AID, suggests that the in- " PREGNANT SO. 70. ~ ~~ 'N~ i ~. a ~ ~g: ",,-~~~~~ o. BELOW SO 60 I Fig. 2.,, Q, Q 2 % INITIAL MOTllIliY I Sperm motility and successful AIR

7 38 PAYNE & SKEELS Fertility & Sterility semination procedure, per se, has no great value in the treatment of infertility, and that AIH is not a substitute for good semen. SPLIT SPECIMEN INSEMINATION AIH using the split specimen technic was performed in 27 patients (78 inseminations). Four pregnancies could be attributed to this method. The patient ejaculates semen into two wide-mouth beakers, trying to collect the first third in one, and the remainder in the other. In many instances the sperm count and quality was significantly better in the first portion, although occasionally the second portion was found higher. Only the superior portion is used for insemination. If in a given case there was little significant difference in the two parts, the method was abandoned. The technic is most valuable in patients whose oligospermia is associated with higher than average semen volume (4 to 5 cc. or more). One patient, whose control counts were from 25 to 40 million per cc. could consistently concentrate to 72 to 103 million per cc. in the first specimen while the second portions were from 2 to 15 million per cc. When sperm counts are low and semen volume high, the split specimen technic may be an effective method for improving sperm concentration. CAP VS. PARACERVICAL INSEMINATION In 1950 Whitelaw popularized the cervical cap method of insemination and noted a marked increase in salvage of 32 couples where oligospermia was a major problem. Approximately half of each of our series of 336 AID's and 382 AIH's were done by cap and the other half by paracervical insemination, with no appreciable difference in the results except that the cap method saves time and is usually more convenient for both patient and physician. CONCLUSIONS 1. All conceptions by donor insemination occurred from 2 days prior to 2 days after the low point preceding the sustained rise in the BT curve. 2. BT graphs are one of the best criteria for determining optimal timing for intercourse (insemination). 3. AIH is a useful tool for evaluating the fertilizing potential of semen. 4. No conceptions occurred with semen counts below 20 million and

8 Vol. 5, No.1, 1954 AI AND FERTILITY 39 motility below 20 per cent. The first quartile fell below 60 million per cubic centimeter and 65 per cent motility. 5. The fractional ejaculate technic of AIH is of value in improving sperm concentration in some patients whose oligospermia is associated with a high ejaculate volume. 6. The high failure rate of AIH as compared to AID, suggests that AIH has no great value per se, in the treatment of infertility. A few exceptions where poor sperm transfer is a major factor, should be noted. REFERENCES 1. CAMPOS DA PAZ, A. Fertil. & Steril. 4:137, COHEN, R. C., STEIN, 1. F., SR., and KAYE, B. M. Fertil. & Steril. 3:201, FARRIS, E. J. J.A.M:A. 138:560, HAMAN, J. O. Am.]. Obst. & Cynee. 64A:34; HANSON, F. M., and ROCK, J. Feml. & Steril. 2:162, MACLEOD, J. In Studies on Testis and Ovary, Eggs and Sperm (ed., Earl T. Engle). Springfield, Ill., Thomas, ROLAND, M. Am. J. Obst. & Cynee. 63:81, SmELDS, F. E. Fertil. & Steril. 1:271, SIEGLER, S. L., and SIEGLER, A. M. Fertil. & Steril. 2:287, WHITELAW, M. J. Fertil. & Steril. 1:33, Meeting in London The 1954 meeting of the Society for the Study of Fertility, of Great Britain, will be held at the Meeting House of the Zoological Society of London, Regent's Park, London, N.W.1 from Thursday, July 22 to Saturday, July 24, It is hoped that many of our colleagues will plan to attend this meeting prior to the International Congress of Obstetrics and Gynecology at Geneva. For further details, readers should write to Mr. H. H. Fouracre, Secretary of the Society, 31 Weymouth Street, Portland Place, London, W.1, England.