Yesterday I went for my first IUI, and the nurse told me that the opening to my cervix was so small that she could not thread the catheter into the uterine cavity. She did ICI instead, but I don't hold out much hope for success. I have virtually no cervical fluid because of laser surgery I had 12 years ago for HPV, which destroyed the glands that create the cervical fluid. What are my options now? I'm not sure what to do next.

K.K.

Intrauterine insemination (IUI) -- a procedure to introduce sperm to the uterus -- involves threading a tiny catheter through the cervix (the opening of the uterus) into the endometrial cavity (the inside of the uterus). This can improve the chances of conception in a given month by placing large numbers of sperm into the endometrial cavity. The injected material consists of concentrated sperm, cleansed of semen fluid and combined with a small amount of nutrient medium. IUI can improve the chances of conception for couples with a wide range of fertility problems, both male and female.

However, if the cervix is closed or scarred, it may be impossible for a doctor to insert the catheter and carry out IUI. Such narrowing of the cervical opening, called cervical stenosis, is an occasional side effect from treatment of precancerous lesions (dysplasia) of the cervix. Such treatment is often done after a woman has repeatedly abnormal Pap smears, which indicate the possible development of cancer. Cervical abnormalities often reflect infection with HPV, the human papilloma virus, a cause of cervical cancer. There are a variety of available treatments to remove abnormal areas from the cervix, and all of them involve some risk of scarring or other damage to the cervix.

When IUI is impossible, some physicians may choose intracervical insemination (ICI). However, this procedure offers little benefit over intercourse, so I do not offer it to my patients.

When cervical stenosis makes IUI impossible, surgical correction may successfully address the problem. An outpatient surgical procedure is performed to dilate the cervix. After placing the woman under either a general anesthetic or regional anesthesia with an epidural or spinal block, the doctor places a series metal dilators into the cervix. Each one is slightly larger than the previous one; the procedure thereby gradually stretches open the cervical canal. Unfortunately this procedure does not work for everyone. Occasionally the scarring is too serious, and the cervical canal cannot be reopened. Complications of the procedure are rare; they may include perforation of the uterus or re-closing of the cervical opening. But for most women with cervical stenosis, cervical dilation usually allows IUI to be performed without difficulty.