Conjugal artificial insemination or homologous (aih/hai)

Definition This is the procedure where the pre-selected sperm of the couple are placed in the reproductive system of the woman during her ovulatory cycle.

There are variations, depending on the anatomical location where the sperm are left, which can be any one of the following: cervical, intraperitoneal, intrafallopian or intrauterine. The most commonly used one, and which provides the best overall performance, is intrauterine insemination (1).

The purpose of insemination is to shorten the journey that sperm need to travel to make contact with the eggs, avoiding chemical or physical barriers such as the acidic pH of the vagina and the cervical crypts.

According to data from ESHRE, 144,509 cycles were performed in Europe in 2008 (2). Conjugal artificial insemination is a widely used technique as it is a low-complexity technique, using stimulation and simple sperm preparation and with few complications, without the need to restrict the patient’s activity (3).

Indications (4) (5)

  • Male Factor.
    • Mild or moderate alterations in the semen.
      • An excess of seminal fluid can be toxic and dilute the sperm.
      • High viscosity may retain the sperm.
      • oligoasthenozoospermia with a MSC above 3 million
  • Sexual Factor, inability to deposit the sperm by sexual intercourse.
    • Male: premature ejaculation, psychogenic or neurogenic impotence or hypospadias.
    • Female: vaginismus.
  • Cervical Factor.
    • Physical alterations due to stenosis and tumours.
  • Serodiscordant couples that need sperm washing when male is HIV positive to prevent horizontal transmission.
  • Sterility of unknown origin..
  • Ovulatory Factor such as Polycystic ovarian syndrome, corpus luteum deficiency, alterations of the folicular phase and anovulation.
  • Mild endometriosis (grade I-II of the American Fertility Society) without tubal involvement.

Fresh semen is usually used, but it can come from a cryo-preserved sample provided we have a sufficient MSC after thawing. In those exceptional cases in which frozen semen is used an accumulation of several samples may be needed to achieve a minimum of MSC.

Mimimum requirements:

  • Hysterosalpingography showing tubal permeability.
  • Seminogram with sperm capacitation test of over 3 million.

The MSC (motile sperm count) is the sample processing aimed at selecting the best quality sperm population, and eliminating microorganisms, seminal plasma and contaminated cells.

Different techniques have been developed without any particular one standing out above the other such as (6) centrifuge-wash, swim-up, Percoll density gradient centrifugation, glass wool column filtration or gel filtration columns.

Good prognostic factors (7)

  • Woman under the age of 30
  • Multi-follicular ovulation
  • Good ovarían reserve.
  • Absence of tubal factor.
  • Absence of endometriosis.
  • No history of previous pelvic surgery
  • SCM above 5 millones/ml
  • Performed fewer than 4 cycles.

Implementation of the AIH technique at Eugin

Stimulation phase (8)

There are several possibilities for stimulation (9). We choose to use gonadotropins. The initial guideline will vary from 50 to 100 IU, adjusting it to the characteristics of the patient (BMI, ovarian reserve markers, response to a previous cycle and age) in order to perform a mild stimulation for bi-follicular development (10).

Normally we start the stimulation on the 3rd day of the cycle and we programme the first control after 4-5 days of stimulation.

Follicular monitoring always consists of an ultrasound measurement of the average of the largest diameters of the growing follicles and the endometrial thickness; and a hormonal check that includes estradiol, LH and progesterone, so that a comprehensive monitoring of the cycle is performed. The scheduling of the successive controls are subject to the results of the previous controls of the cycle that is underway and of the preceding cycle. We do not use pituitary down-regulation drugs, except for some exceptions, as they do not show that they obtain better results. (11)

Ovulation discharge

The discharge will generally be programmed with 250 micrograms of Ovitrelle between 36-42 hours prior to insemination when we have a follicle with a mean diameter ≥ 17mm, and hormone levels that are in concordance. If the result of the hormonal study indicates a naturally premature LH peak, the time of insemination will be adapted to the specific case.

The insemination technique

On the day of insemination the male partner must leave a new semen sample, preferably after 3-5 days of abstinence. They then proceed to the capacitation of the semen sample. Once the sample has been capacitated, we proceed to its injection inside the uterus. Next, the woman remains in a supine position on the stretcher for10 minutes and can then continue with a normal life. According to current evidence we cannot say that a double insemination increases the success rate (12) (13). To this must be added that by making diagnoses of LH, progesterone and estradiol in each control phase it allows us to define and synchronize insemination with the ovulation in a much more suitable way.

Luteal support phase

We recommend the application of 200mg of vaginal micronized progesterone from the night of the AIH (14,15) (16,17) and advise that a pregnancy test be taken14 days later.
It is a simple and convenient procedure if well indicated. Indefinite continuation in time and unlimited repetition of cycles should be avoided.

Bibliography

(1) O’Brien P, Vandekerckhove P. WITHDRAWN: Intra-uterine versus cervical insemination of donor sperm for subfertility. Cochrane Database Syst Rev 2007 Jul 18;(4)(4):CD000317.

(2) Ferraretti AP, Goossens V, de Mouzon J, Bhattacharya S, Castilla JA, Korsak V, et al. Assisted reproductive technology in Europe, 2008: results generated from European registers by ESHRE. Hum Reprod 2012 Sep;27(9):2571-2584.

(3) Katzorke T, Kolodziej FB. Significance of insemination in the era of IVF and ICSI. Urologe A 2010 Jul;49(7):842-846.

(4) Bry-Gauillard H, Coulondre S, Cedrin-Durnerin I, Hugues JN. Benefits and risks of ovarian stimulation before intrauterine insemination. Gynecol Obstet Fertil 2000 Nov;28(11):820-831.

(5) Bajo J, Coroleu B. Fundamentos en Reproducción. Madrid: Panamericana; 2009.

(6) Boomsma CM, Heineman MJ, Cohlen BJ, Farquhar C. Semen preparation techniques for intrauterine insemination. Cochrane Database Syst Rev 2007 Oct 17;(4)(4):CD004507.

(7) Merviel P, Heraud MH, Grenier N, Lourdel E, Sanguinet P, Copin H. Predictive factors for pregnancy after intrauterine insemination (IUI): an analysis of 1038 cycles and a review of the literature. Fertil Steril 2010 Jan;93(1):79-88.

(8) Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2012 Sep 12;9:CD001838.

(9) Cantineau AE, Cohlen BJ, Heineman MJ. Ovarian stimulation protocols (anti-oestrogens, gonadotrophins with and without GnRH agonists/antagonists) for intrauterine insemination (IUI) in women with subfertility. Cochrane Database Syst Rev 2007 Apr 18;(2)(2):CD005356.

(10) van Rumste MM, Custers IM, van der Veen F, van Wely M, Evers JL, Mol BW. The influence of the number of follicles on pregnancy rates in intrauterine insemination with ovarian stimulation: a meta-analysis. Hum Reprod Update 2008 Nov-Dec;14(6):563-570.

(11) Cantineau AE, Cohlen BJ, Klip H, Heineman MJ, Dutch IUI Study Group Collaborators. The addition of GnRH antagonists in intrauterine insemination cycles with mild ovarian hyperstimulation does not increase live birth rates–a randomized, double-blinded, placebo-controlled trial. Hum Reprod 2011 May;26(5):1104-1111.

(12) Polyzos NP, Tzioras S, Mauri D, Tatsioni A. Double versus single intrauterine insemination for unexplained infertility: a meta-analysis of randomized trials. Fertil Steril 2010 Sep;94(4):1261-1266.

(13) Osuna C, Matorras R, Pijoan JI, Rodriguez-Escudero FJ. One versus two inseminations per cycle in intrauterine insemination with sperm from patients’ husbands: a systematic review of the literature. Fertil Steril 2004 Jul;82(1):17-24.

(14) Feinberg EC, Beltsos AN, Nicolaou E, Marut EL, Uhler ML. Endometrin as luteal phase support in assisted reproduction. Fertil Steril 2013 Jan;99(1):174-178.

(15) van der Linden M, Buckingham K, Farquhar C, Kremer JA, Metwally M. Luteal phase support for assisted reproduction cycles. Cochrane Database Syst Rev 2011 Oct 5;(10):CD009154. doi(10):CD009154.

(16) Erdem A, Erdem M, Atmaca S, Guler I. Impact of luteal phase support on pregnancy rates in intrauterine insemination cycles: a prospective randomized study. Fertil Steril 2009 Jun;91(6):2508-2513.

(17) Cohlen BJ. Should luteal phase support be introduced in ovarian stimulation/IUI programmes? An evidence-based review. Reprod Biomed Online 2009;19 Suppl 4:4239.

Last Updated: November 2017