The unfulfilled promise of intrauterine insemination treatment

This is an opinion article by an external contributor. The views belong to the writer.

Forty-four years ago, Mr. and Mrs. Brown’s patience and persistence got rewarded. Mrs. Brown finally conceived after 9 years of trying unsuccessfully after undergoing an experimental procedure now known as in-vitro fertilization (IVF).

A lot of patience and persistence was also needed for her physicians, Drs. Steptoe and Edwards as her pregnancy occurred on their one hundredth and second tedious experimental treatment attempt; a fact they did not disclose to their desperate patients. A lot has changed in the landscape of IVF treatment since their Nobel prize worthy feat on the 10th of November 1977. Most couples who will be successful with IVF treatment do so in their first three IVF treatment attempts.

Intrauterine insemination (IUI) treatment has a longer history but suffered more controversies than IVF. Its role and efficacy in fertility treatment have been topic of many articles and scientific meetings. While IVF has experienced a 40-fold increase in success rates since its inception, the efficacy of IUI has remained relatively unchanged at fifteen percent per treatment cycle. 

Multiple steps, most of which have yet to be identified, are necessary to achieve a complex event like a pregnancy. Firstly, the release of a mature egg by the ovary requires orchestrated hormone production as well as a threshold number of eggs. Secondly, successful fertilization requires that a threshold number of sperms make it to the site of ovulation at the right time. Finally, the implantation of the fertilized egg requires a primed uterine lining. When all these have been accomplished, the couple gets rewarded with a pregnancy thirty percent of the time. 

Couples who in spite of being capable of all the aforementioned steps and are yet unable to conceive after twelve months are classified as having an unexplained fertility problem.

The absence of the enigmatic endometriosis is usually necessary to secure the title of unexplained infertility. Endometriosis is a hormone-driven disease whose presence alone decreases the chance of pregnancy in ways that are not always clear. It has been postulated that given the difficulty in diagnosing endometriosis, it could be the unexplained in the unexplained sub-fertile group.

Advancing female age impacts most of the above listed steps and therefore negatively affects pregnancy rates. Ovulation occurs less regularly with age. The increase in rates of genetic mutation in oocytes coupled with a less competent uterine lining result in the formation of a weakened embryo unable to implant.

It is also possible that the some of the unidentified steps necessary to achieve pregnancy are defective in these group of couples. In a woman less than 35 years without identifiable endometriosis or any other defects, who did not get pregnant in the first year; the chance of getting pregnant without treatment is about 25% after 1 year.

Intrauterine insemination treatments attempt to increase pregnancy rates by ensuring timely placement of a threshold number of sperm cells closer to the site of ovulation. In an attempt to improve pregnancy rate and borrowing its cue from IVF, IUI now involves ovarian stimulation to increase the number of mature eggs available for fertilization.

Unlike IVF where all the embryos that result from the fertilization of multiple mature eggs are prevented from implanting in the uterine lining all at the same time, there is no way to control this in an IUI treatment cycle. There is as a result, more unintended multiple pregnancies.

Couples often imagine a twin pregnancy as an efficient solution to their longing for a child.  However, multiple pregnancy increases the chances of unhealthy pregnancy and unhealthy children. There is an increased maternal risk of preeclampsia, maternal gestational diabetes, preterm labor and delivery. There is also a 4-fold increased risk of perinatal mortality in twin pregnancies. This limits super ovarian stimulation as a successful strategy during IUI treatment.

IVF directly improves most steps from egg to baby; from super ovulation to fertilization to the deposition of embryos in the uterus. IUI, on the other hand, directly improves timing and sperm proximity to the egg; everything else, especially fertilization is left to nature. Improving sperm treatment and selection during IUI treatment has the potential to directly impact fertilization.

Stress management might be more important in IUI than IVF treatments given the large their difference in pregnancy rates. Any factor that deters pregnancy will disproportionately affect IUI. Stress is known to negatively affects both female and male reproduction and by extension pregnancy rates

IUI in its current stage needs major upgrade before it can be convincing as a safe and effective improvement over no treatment. Research should be directed at improving sperm treatment and selection. Stress assessment and management strategies should be part of IUI treatment.

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