Artificial insemination is the placement of sperm into a woman’s reproductive tract by other than natural means. The sperm is most often placed in the uterus (intrauterine insemination) or in the cervix (intracervical insemination).

Couples with fertility issues may benefit from artificial insemination. It may be recommended for numerous fertility problems, including low sperm count, impotence, poor interaction between sperm and cervical mucus, endometriosis and unexplained infertility. In these cases, the sperm can be collected and prepared in a way that allows it to be placed into the woman’s reproductive tract. The procedure is typically performed when the woman is ovulating. A number of methods may be used to determine the time of ovulation, including an ovulation test, basal body temperature chart and a cervical mucus examination.

For couples, the cause of infertility must be diagnosed before the procedure is performed. The male’s sperm is analyzed to determine if it is suitable for insemination. Blood tests and ultrasounds may be performed on the woman to determine if she is ovulating normally. For women with irregular ovulation patterns, drugs are frequently used to induce ovulation prior to artificial insemination.  

In some cases, the male partner’s sperm cannot be used for insemination. In these situations, a donor’s sperm can be used. Donor sperm is saved and frozen and is available from sperm banks around the country. The donors are tested for infectious diseases and screened for certain genetic diseases. This option may also be recommended for women without a male partner who wish to become pregnant.  

The American Society for Reproductive Medicine estimates that the success rate of artificial insemination may be as high as 15 percent each cycle. Although success rates are higher for other forms of fertility treatments, artificial insemination is often one of the first methods used. It is less invasive and less expensive then more complex procedures, such as in vitro fertilization.

A method of fertility treatment, artificial insemination is the placement of sperm into a woman’s reproductive tract by means other than sexual intercourse. The procedure can be performed using either a sexual partner’s sperm (husband insemination) or a donor’s sperm (donor insemination).

The two most common types of artificial insemination procedures include intracervical insemination (ICI) and intrauterine insemination (IUI). ICI involves placing especially prepared (or “washed”) semen inside the cervix. During IUI, sperm is injected directly into a woman’s uterus. This allows the sperm to bypass the cervix enabling more sperm to successfully reach the uterine cavity and fallopian tubes where fertilization usually takes place. Both procedures are typically performed at the time of ovulation.

Less common techniques include intrafallopian insemination and intraperitoneal insemination. During these procedures sperm is placed near the mouth of the fallopian tubes and ovaries. Intravaginal insemination is also used on rare occasions. This method places sperm into the vagina.

Couples with infertility issues may benefit from artificial insemination if their problems are related to factors that make it difficult or impossible for the man’s sperm to reach the woman’s uterus. This may be due to issues with the man’s sperm or conditions that prevent the sperm from entering the uterus from the vagina. Artificial insemination may be recommended when the couple or one partner is diagnosed with:

• Unexplained infertility
  
  
• Impotence
  
  
• Premature ejaculation
  
  
• Low sperm count
  
  
• Decreased sperm motility (decreased ability to move)
  
  
• Abnormal sperm morphology (abnormal shape and structure)
  
  
• Sperm antibodies (antibodies produced by the body to destroy the sperm)
  
  
• Hypospadias (a condition in which the urethra opens on the underside of the penis)
  
  
• Drug-induced erectile dysfunction
  
  
• Poor interaction between sperm and cervical mucus
  
  
• Cervix disorders
  
  
• Mild endometriosis
  
  
• Retrograde ejaculation (a condition that causes semen to be released backward into the bladder at male climax)

Artificial insemination may improve the chances of fertilization in couples with these fertility issues. For women undergoing ovulation induction (a form of fertility treatment), the chances are greatly increased because timing the insemination procedure with ovulation is essential.   

Women may also undergo artificial insemination using sperm from a man other than their partner. The donor may be a friend, non-blood relative or an anonymous stranger. Known as donor insemination, this procedure may be recommended for a number of situations, including:

• Male partner infertility (e.g., azoospermia, severe oligospermia or other severe semen abnormalities resulting in infertility).
  
  
• One or both partners carry a heritable disorder. A couple may choose donor insemination when there is potential for hereditary disease in their offspring.
  
  
• Male partner has a sexually transmissible viral infection. Men who have a sexually transmissible viral infection, such as human immunodeficiency virus (HIV) and some forms of hepatitis, risk transmitting the infection to their partner through their semen.
  
  
• Absence of a male partner. Single women and lesbian couples can achieve pregnancy through donor insemination.
  
  
• Failed assisted reproductive technology (ART). Donor insemination may be recommended when ART methods, such as in vitro fertilization (IVF), have failed to result in pregnancy. 

Artificial insemination is not recommended for women who are less fertile because of tubal factors, uterine malformations, active pelvic infection or anovulation (failure or absence of ovulation).

Before a woman undergoes artificial insemination, the cause of the infertility must be determined. In addition, the male partner’s sperm must be analyzed to determine if it is suitable for insemination. The woman must also have the regularity of her ovulation tested.

For couples, the process begins with a physician’s visit. The physician will take a medical history from both partners, and both will undergo a physical examination. Testing for human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) may also be performed.

The woman’s evaluation will include a pelvic exam. For women whose medical history or physical exam suggests a possibility of infection, tubal damage or endometriosis, a hysterosalpingogram, hysteroscopy or laparoscopy may be recommended. These tests allow the physician to check for obstruction in the fallopian tubes. In addition, an endometrial biopsy may be performed to determine if the ovaries are producing enough hormones. In addition, several blood tests may be required as part of the general infertility evaluation.

During the male partner’s examination, he will be asked to provide several semen samples for analysis. Sperm analysis examines sperm count, whether the sperm are formed normally and able to move freely, and sperm survival over a period of time. Testing may also include sperm antibody tests and sperm penetration assays (tests used to determine if a man’s sperm can travel through cervical mucus and penetrate an egg).

The results of these tests will be used to pinpoint the fertility problem. When the male partner’s sperm is normal, the woman may be monitored with blood tests and ultrasounds to determine if she is producing and releasing a mature egg every month. Blood tests allow the physician to measure levels of the hormone LH (luteinizing hormone) and, at times, estradiol levels. These levels can help determine if the woman is producing a mature egg. Ultrasounds enable the physician to monitor the growth of ovarian follicles and to verify that the egg is released from the follicle. 

For women with irregular ovulation, the physician may prescribe drugs to induce ovulation. These medications increase as well as coordinate egg production. They are usually given in pill form or may be given as an injection to trigger the release of the mature follicle or egg. For women who are getting their menstrual period less than two weeks after ovulation, physicians may also recommend the hormone progesterone.

Once a woman is determined to be a suitable candidate for artificial insemination, the next step is pinpointing the time of ovulation. Artificial insemination cannot be successful unless it is performed when the woman has a mature egg. To determine the time of ovulation, an ovulation test, basal body temperature chart and a cervical mucus examination may be used. Blood tests and ultrasounds may also be used.  When the woman is ovulating, her partner will be asked to produce a sample of semen for the insemination procedure. Men may be advised to abstain from sexual intercourse during the three days before the sample is taken. This ensures a good-quality sample. If there is no partner providing the sperm, the woman will obtain the sperm from another source, such as a sperm bank.

The required sperm can be collected in a number of ways, including:

• Cup collection. This method requires a man to masturbate and ejaculate into a sterile cup. It can be done in the home or at the physician’s office. The sample must be collected no more than two hours before the scheduled insemination appointment.
  
  
• Condom collection. During this process, semen is collected during intercourse using a special condom provided by a physician. 
  
  
• Split ejaculate. This method uses a two-part container to collect sperm. The initial spurt should be collected in one part of the container, and the rest is collected in the second part.
  
  
• Urine collection. During this process, semen is collected from urine in a laboratory. This is an option for men who have retrograde ejaculation, a condition that causes semen to be released backward into the bladder at male climax.

In some cases, men having treatments that cause or may cause sterility, including vasectomy, testicular surgery, prostate surgery, radiation and/or chemotherapy for cancer treatment, may choose to store their sperm for future use in an artificial insemination.

Women using donated sperm should have the sample on hand. Sperm banks can either ship the sperm to the woman’s home or to her physician’s office. Donated sperm is available from sperm banks around the country. Anonymous donors are screened for infectious diseases, as well as certain genetic diseases, depending on their genetic background. Because of the high risk of disease transmission during artificial insemination, sperm banks no longer use fresh sperm. Instead, the sperm is frozen and quarantined for a minimum of 180 days. The donor is then retested for infectious disease. If the donor tests negative again, the sperm is approved for use. The donated sperm, which can be frozen indefinitely, is stored in containers of liquid nitrogen until it is shipped upon request.

When the sperm being used is from a donor the woman or couple knows, fresh sperm can be used. However, physicians often insist that the donor have all testing for infectious diseases up to date.

Sperm being used for an intrauterine insemination (IUI) must be specially prepared before the procedure. Semen is composed of sperm and plasma (substances that nourish the sperm, not to be confused with blood plasma). In a process known as “washing”, the sperm is separated from the plasma. During the procedure, the semen is diluted with a sterile fluid. The sperm is then separated from the liquid component (plasma). Separating these two components removes substances that may cause complications.

Semen contains proteins, prostaglandins and bacteria. The introduction of these substances into the uterus could result in severe uterine pain, cramps, fainting or a life-threatening reaction. The process also concentrates the semen into a small sample of the most active sperm, thus increasing the chance of fertilization. A woman using donated sperm, can request sperm that is ready for intracervical insemination or sperm that is “washed” and ready for IUI. 

Artificial inseminations are scheduled to occur at the time a woman is ovulating. Ovulation occurs when the ovary releases a mature egg. For women with regular menstrual cycles, it usually occurs 14 days before the start of their next menstrual period. Ovulation is often estimated with the aid of ovulation tests, basal body temperature charts and a cervical mucus examination. Blood tests measuring levels of the hormone LH (luteinizing hormone) and ultrasounds may also be used.   

The insemination procedure is usually performed once or twice a month, depending on the regularity of the woman’s menstrual cycle. It is a fairly simple procedure and takes only a few minutes to complete. Artificial insemination may be performed at the office of a gynecologist or in many cases by a physician specializing in infertility (board-certified in reproductive endocrinology). During the procedure, the woman lies back on an examining table with her knees up. Her feet will be placed in stirrups and her buttocks should be located near the end of the table. The physician then inserts a speculum into the woman’s vagina, and injects the semen sample into her reproductive tract.   

During an intracervical insemination (ICI), a plastic syringe is used to inject the semen into the opening of the cervix. Following the injection, a plastic-coated sponge or cap may be placed into the vagina before the speculum is removed. The sponge or cap, which keeps the sperm near the cervix, can be removed by the patient four to six hours after the insemination procedure.  

An intrauterine insemination (IUI) is performed in a slightly different manner. During this procedure, the physician passes a soft tube, known as a catheter, through the cervix to place the sperm directly into the uterus. After the injection, the catheter is slowly withdrawn and the woman is instructed to remain lying flat for approximately 15 minutes. The patient may experience mild to moderate cramping.

Following the procedure, the woman should be able to resume normal activities. Although sexual intercourse has not been proven to interfere with the success of artificial insemination, the woman may be advised to abstain from sexual intercourse for 24 hours after the procedure. Many centers require the woman to return the day after the procedure for an ultrasound. The ultrasound can be used to determine if an egg was released from the follicle. When this occurs, the follicle will appear to have shrunk.

According to the American Society for Reproductive Medicine, the success rate of artificial insemination may be as high as 15 percent each cycle. This rate is based on a number of factors, including:

• The cause of infertility. A couple who is unable to conceive because of a woman’s cervical disorder is more likely to conceive than a couple diagnosed with sperm abnormalities. 
  
  
• Age. Artificial insemination is less likely to be successful in women over age 35.
  
  
• Timing of insemination. The insemination must be done on the expected day of ovulation for fertilization to take place.
  
  
• Ovulation induction. Women taking drugs to induce ovulation are more likely to have a successful insemination.
  
  
• Medical history. Women with endometriosis or a history of pelvic infection or tubal disease are less likely to have a successful artificial insemination.
  
  
• History of pregnancy. The procedure is more likely to be successful in women who have been pregnant before.
  
  
• Condition of sperm. Sperm that has been frozen is less likely to result in pregnancy then fresh sperm.
  
  
• Number of sperm. The higher the concentration of sperm inseminated, the higher the success rate.

Intrauterine insemination (IUI) is the artificial insemination technique with the highest success rate. This procedure most often results in pregnancy because it places the sperm near the fallopian tubes, the site where fertilization normally takes place. However, it is unusual for the first attempt at IUI to be successful. When any form of artificial insemination is successful, it most often occurs within the first six cycles of treatment. When conception fails to occur by this point, other forms of treatment, such as in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), may be recommended.

The success rates for artificial insemination are not as high as they are for some other techniques. However, it is a fairly simple procedure with few side effects. It is less invasive and less expensive then in vitro fertilization (IVF) and other forms of assisted reproductive technology (ART). Artificial insemination also allows for fertilization to occur naturally in the body.

Another benefit of artificial insemination is that it enables women without male partners to conceive. In addition, couples with male fertility problems have a higher chance of conceiving through artificial insemination than through simply timing intercourse. Couples with unexplained fertility problems also have higher success rates with artificial insemination than with the use of fertility drugs alone.

Although artificial insemination is a relatively safe procedure, there are some risks attached. Sperm “washing” is used to remove most of the bacteria and other harmful substances from the semen, but it is impossible to completely sterilize the sperm. As a result, intrauterine insemination can cause an infection in the uterus in some cases. Although it occurs rarely, this infection can result in endometriosis.

The fertility drugs often used in combination with artificial insemination are linked to several side effects. Some women may experience hot flashes, depression, irritability, headaches and restlessness at night. The drugs can also cause ovarian hyperstimulation syndrome, a condition that can result in the formation of ovarian cysts and abdominal pain. The condition may also result in swelling of the ovaries, and the production of several eggs at once, which may result in multiple pregnancy. 

Fertility drugs in general also carry an increased risk of multiple pregnancy. The drugs, used to stimulate ovulation, can trigger the release of more than one egg, resulting in the fertilization of multiple eggs. Carrying two or more babies is associated with an increased risk of premature birth, and having an underweight or disabled baby. In addition, there is also a greater risk of neonatal death.

In addition, a recent study warns that sperm banks may not screen donors for certain rare genetic disorders, such as severe congenital neutropenia ([SCN] a disorder characterized by abnormally low levels of certain infection-fighting white blood cells in the body. Patients with SCN are more susceptible to chronic infections and are at increased risk of developing leukemia (cancer of the blood and bone marrow).

The American Society for Reproductive Medicine (ASRM) requires anonymous sperm donors to provide a full family medical history going back at least three generations. However, ASRM guidelines state that a complete chromosome screening is not required if a proper family history is taken concerning potential hereditary disorders.

Currently, sperm donors in the United States are routinely screened for more prevalent genetic disorders like sickle cell anemia and cystic fibrosis, but not for rare genetic disorders like SCN. Because it is presently difficult to screen for all types of genetic disorders, health experts urge potential mothers to become fully informed and seek genetic counseling prior to undergoing fertility procedures, such as artificial insemination, using donor sperm. 

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or other healthcare professional the following questions about artificial insemination:

1. Am I a candidate for artificial insemination?
   
   
2. Which type of artificial insemination will be used with me?
   
   
3. What are the odds of the procedure resulting in pregnancy?
   
   
4. Is there a chance I will have a multiple pregnancy?
   
   
5. What tests are required for me and my partner before the procedure?
   
   
6. Can I use my partner’s sperm? If so, what is the best method for obtaining it?
   
   
7. Where can I obtain donated sperm?
   
   
8. What is the process in choosing a sperm donor?
   
   
9. What information will I know about the donor?
   
   
10. Is there anything I can do before or after the procedure to improve the chance of success?
    
    
11. What are the risks associated with the procedure?
    
    
12. How often can I repeat artificial insemination?
    
    
13. What is your success with this procedure?
    
    
14. What costs are involved with artificial insemination?