I am considering artificial insemination but am not too sure of the processes and the procedures. What is the difference between intracervical insemination and intrauterine insemination? I gather that one is through the cervix, but the other one I'm not too sure about. Also, are either of these procedures painful at all?

R.C.

Artificial insemination has become an important part of most fertility treatment plans. Insemination is often recommended if the sperm count is low or the motility is diminished.

Recent studies comparing intracervical insemination (in which the sperm is placed into the cervix) and intrauterine insemination (in which it is placed directly into the uterus) report dramatic improvement with intrauterine insemination. In fact, a review of these studies shows little reason to perform the less-effective cervical insemination procedure. Of particular interest is that cervical insemination has not been shown effective for managing unexplained infertility (in which no cause for the infertility can be identified). However, the use of intrauterine insemination can often improve pregnancy rates for couples with unexplained infertility, or when combined with ovulation induction for women who do not ovulate regularly.

Some physicians also recommend insemination after an abnormal result on a postcoital test, which involves checking for the presence of motile sperm in the cervical mucus 3-24 hours after intercourse. However, the postcoital test and mucus check is such a poor indicator of who will conceive that I no longer recommend this test. Even if "poor mucus" is cited as the reason for insemination, intracervical insemination would offer no benefit; only intrauterine insemination would bypass the presumed mucus problem.

Intrauterine insemination does require that the physician or laboratory prepare the sperm, separating the sperm cells from the seminal fluid. The seminal fluid contains very high levels of prostaglandins, the chemicals responsible for uterine cramps; these compounds can be toxic if injected directly into the uterus. So, if for some reason the physician did not perform a sperm-washing procedure or another sperm preparation procedure before the insemination, severe pain might be the result.

However, in my experience (actually my patients' experience), the procedure usually is not painful. Discomfort should be no worse than mild cramping. Factors affecting the amount of discomfort include adequacy of sperm preparation, type of catheter used for the insemination, the presence of a sharp bend in your cervical canal (this may occur if your uterus is tipped at a greater angle than average), and the experience and care your physician exercises in performing the procedure.