[advanced fertility issues]

Information for TTC Couples...

Written by TTC Couples.

 

Frequently Asked Questions about Intrauterine Insemination (IUI)







 IUI FREQUENTLY ASKED QUESTIONS

Q: What is an IUI and how is it done?

A: An IUI -- intrauterine insemination -- is performed by threading a very thin flexible catheter through the cervix and injecting washed sperm directly into the uterus. The whole process doesn't take very long — it usually only requires the insertion of a speculum and then the catheter, a process that maybe takes a couple of minutes (60-90 seconds to introduce the catheter, then sperm injection, and another 60 seconds or so to remove the catheter — going slowly helps reduce discomfort). Sometimes when the cervix is hard to reach a tenaculum is used to hold the cervix, which makes the process a bit more uncomfortable. A typical "Tomcat" catheter is shown below.

tomcat.jpg - 25639 Bytes


Q: Where is the sperm collected? How long before the IUI?

A: Usually the sample is collected through ejaculation into a sterile collection cup, but it is also possible to obtain collection condoms for this purpose (through the doctor's office -- Milex is one company that makes them). Most clinics want the semen to be delivered within a half hour of ejaculation, around the time of liquefaction, so if one lives close enough the sample can be collected at home. If not, one has to make do with a room at the clinic, a bathroom, or any private setting.

There is a delay between when the semen sample is dropped off for washing and when it is inseminated. The amount of time depends on the washing technique used, which takes 30 minutes to two hours, as well as on the clinic's scheduling. Most will perform the IUI as soon after washing is completed as possible.

Q: When is the best timing for an IUI?

A: Ideally an IUI should be performed within 6 hours either side of ovulation — for male factor infertility some doctors believe after ovulation is better, otherwise chances of success are higher with insemination before ovulation with the sperm waiting for the egg. When timing is based on an hCG injection, the IUIs are usually done between 24 and 48 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG, though some do it at 24 hours, and some clinics are reporting better results when doing the IUI at 40-42 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the hCG. Some reports show no increase in success rates with two IUIs, but others suggest it may increase success as much as 6 percent.

Some doctors will base timing of IUI on a natural LH surge. In that case, a single IUI at 36 hours is the norm, but doing them at 24 hours is also pretty common since ovulation may be a bit earlier. When two inseminations are planned, they are usually timed between 12 and 48 hours after the surge is detected.

The egg is only viable for a maximum of 24 hours after it is released.

Q: What is the success rate for IUI?

A: Searching through about a dozen medical journal articles and a number of web sites resulted in a rather wide range of statistics. Basically the odds of success are reported to be just under 6 percent and as high as 26 percent per cycle. The low statistics are with one follicle, while multiple follicles resulted in as high 26 percent success. Another influencing factor is sperm count. Higher sperm counts increase the odds of success; however, there was little difference between success with good-average counts and those with high counts. The overall success rate seems to be between 15-20 percent per cycle, judging from the articles which will be abstracted below. The rate of multiple gestation pregnancies is 23-30 percent.

Q: What does an IUI feel like?

A: Most women consider IUI to be fairly painless -- along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is ovulation-related rather than from the IUI. The catheter usually doesn't feel like much since the cervix is already slightly open for ovulation -- a poorly timed IUI might cause more discomfort at the cervix. See the personal experiences below for more details.

Q: How long does washed sperm live?

A: Current research indicates that washed sperm can live 24-72 hours; however, it does lose potency after 24 hours. Another issue with IUI is that the sperm can keep on swimming beyond the fallopian tube, so the ideal window is really within 6-12 hours of the egg being released, with a larger margin before ovulation than after since the egg's viability is shorter. Sperm can live up to 5 days in fertile mucus, 2-3 days being pretty common, so combining IUI with intercourse may provide better coverage.

Q: Do I have to lay down after an IUI?

A: You don't have to lay down because the cervix doesn't remain open, but most doctors let patients lay down on the table for 15-30 minutes after the procedure.

Q: Do I need to take it easy after an IUI?

A: Most people don't need to, but if you had cramping or don't feel well afterward it makes sense to take it easy for awhile. Some people reduce their aerobic activity and heavy lifting during the luteal phase in hopes it will increase the chance of implantation. It is more important to take it easy for a bit after IVF, as that is a more invasive process.

Q: How long before an IUI should the male abstain from intercourse/ejaculating and store up sperm?

A: This depends on your individual situation, but it usually should not be more than than 72 hours since his last ejaculation in order to ensure the best motility and morphology. Where low sperm count is the reason for IUI, it is generally best to wait 48 hours between ejaculation and collecting sperm for the IUI. With no sperm count issues, it makes sense to wait at least 24 hours. Some suggest trying for about 36 hours to cover the most territory with the highest counts — a common suggestion is to have intercourse around the time of hCG injection.

Q: How soon after an IUI can I have intercourse?

A: Usually you can have intercourse anytime after an IUI . . . in fact, most doctors suggest having intercourse, when that is an option, soon after the last IUI to help make sure ovulation is covered. Your doctor may suggest waiting 48 hours to resume relations if you had any bleeding during the IUI or if a tenaculum is used.

Q: Can the sperm fall out?

A: Once the sperm is injected into the uterus, it does not fall out. There can, however, be increased wetness after the procedure because of the catheter loosening mucus in the cervix and allowing it to flow out. Some doctors will insert a cup around the cervix to prevent leakage, but most do not.

Q: How come I feel wetter after the IUI — like the sperm is falling out?

A: The catheter loosens cervical mucus and lets it come out more easily. It is common to see more fertile mucus after an IUI for this reason, as well as the fact that well-timed IUI should be close to ovulation.

Q: How many follicles give my best chance of getting pregnant?

A: According to different studies, either 3-4 follicles gives one the best chance of getting pregnant, while more follicles beyond that simply increases the risk of multiples. The U.S. study said 4 follicles, while other countries have data stating 3. The U.S. has a higher rate of multiple births, so 3 may be more likely to be the correct answer.

Q: Does IUI make sense when there isn't a sperm count problem?

A: IUI can help on Clomid cycles where cervical mucus is a problem, and IUI increases the chance of success on injectable cycles no matter what the sperm count. It does make sense to try IUI if you can and haven't had success with intercourse. It is important to note that with intercourse, only the best and strongest sperm make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI, more sperm will be available for fertilization.

Q: How high a sperm count is needed for IUI?

A: A count above one million washed appears necessary for success, with a significant reduction in pregnancy rates when the inseminated is count is lower than 5-10 million (in other words, in most cases one should consider 5 million a lower limit for success, 10 million for cost-effective). Higher success rates are with washed counts over 20-30 million, while increasing counts over 50 million did not appear to offer advantage. Advanced Fertility has a chart of success rates for one month of various treatments.

Q: How many IUIs should I try before moving on to IVF?

A: It depends on what you can afford and what meds you are doing. One might do 3-4 IUIs on Clomid before moving on to injectables, then do 3-4 cycles on injectables. If one doesn't have success after four good ovulatory cycles on injectables with well-timed IUI, it would be time to consider IVF.

Q: Can IUI be done at home?

A: An IUI shouldn't be done at home without medical supervision because the sperm needs to be washed to prevent infection -- i.e., separated from the semen. A vaginal insemination can be done at home, but is no more successful than intercourse. Some doctors are willing to instruct on doing ICI (intracervical insemination) at home, but it should not be attempted without being taught proper technique. Getting semen or air into the uterus could be quite dangerous -- perhaps life-threatening. One woman wrote in to say there is a midwife practice in Berkeley, CA, that will do inseminations at the patient's home, so it may be worth asking about.

Q: Is bleeding common after an IUI?

A: It doesn't usually happen, but it isn't uncommon. It is most common to have some bleeding if the doctor had trouble reaching the cervix. Some women also have light bleeding with ovulation.

Q: How long after IUI should implantation occur?

A: Implantation generally takes place 6-12 days after ovulation — so 6-12 days after a well-timed IUI. See abstract.

Q: How much does IUI cost?

A; This is definitely something to consult your doctor or clinic about as the price varies considerably. Ask for a rate sheet, if available, and also ask what your cycle is likely to entail. The IUI procedure and sperm washing average $200-300, but the cost of medications, ultrasounds and bloodwork can make a considerable difference. Someone doing a natural IUI cycle may spend only $200, while someone on injectable medications with monitoring may spend $5,000-6,000.

Q: What kind of monitoring is usually done for an IUI cycle?

A; This depends mostly on how the female is being treated. A natural cycle is often timed to over the counter ovulation prediction kits, which cost $15-60 for 5-9 tests. The use of clomiphene citrate can increase the monitoring, but many doctors don't do ultrasounds or settle for one u/s around cycle day 12. Gonadotropins increase both medication costs and the necessity of ultrasounds and bloodwork.

Q: At what size are follicles considered mature?

A: Many doctors monitor follicle development during IUI cycles. Most trigger when the dominant follicle is within a certain size range. While there is always some difference in doctor preference, the norms are unmedicated 20-24mm, clomiphene citrate 20-24mm, FSH-only meds 17 or 18mm minimum, and FSH+LH would be 16 or 17mm minimum. It is possible for slightly smaller follicles, 14-15mm, to contain a viable egg. Also, follicles continue to grow until they release, usually at a rate of about 1-2 mm per day. A woman may ovulate more than one follicle in a cycle, but the releases will occur within 24 hours. When hCG is not used, only follicles close in size are likely to release. The use of hCG induces ovulation in about 95 percent of women, and will get most mature follicles to rupture.

Q: What should estradiol (E2) level be at time of hCG trigger?

A: The E2 level should be 200-600pg/ml per 18mm follicle. Some doctors are content with a minimum level of 150, but higher tends to be better.

Q: What are the risks involved in IUI?

Q: The main risks are some discomfort such as cramping, minor injury to the cervix that leads to bleeding or spotting, or introduction of infection (including sexually transmitted disease from the sperm itself — it helps to be sure of the known donor's health, or use carefully monitored frozen specimens). There are also risks of hyperstimulation associated with the use of ovulation induction medications such as clomiphene citrate (low risk) and gonadotropin therapy (higher risk). Proper technique and adequate monitoring reduce risks.

Q: Can I take pain medications before or after the procedure?

A: Most women don't need medication for pain associated with IUI. If there is cramping, it is best to avoid medications such as ibuprofen and naproxen (NSAIDS), but Tylenol is considered safe (but maybe not that helpful for cramps).

Q: What does "sperm washing" mean?

A: It is sometimes also called sperm preparation or spinning. It is a laboratory technique for separating sperm from semen, and separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI, IVF).

The washing technique for near normal specimens is mixing the ejaculate after liquefaction with the appropriate washing medium followed by centrifugation. (A centrifuge is a machine that separates materials with different densities by spinning them at high speed.) The supernatant is discarded and the sediment (sperm rich fraction) is re-suspended in more washing medium. This process is repeated 2-3 times maximum. In the final wash, the sediment is re-suspended in 0.5 cc of medium, loaded into a syringe and deposited in the uterus.

The "Sperm Rise" or "Swim-up" technique is one in which two to five cc of medium are carefully layered on top of 0.2-0.5 cc of semen. Motile sperm cells "swim-up" into the culture medium. After some time (30-90 minutes) the medium (containing motile sperm cells) is carefully harvested and centrifuged. If necessary, fresh medium is layered on top of the seminal fluid again to harvest more sperm cells.

The discontinuous gradient centrifugation technique utilizes a dense liquid phase to separate sperm cells from seminal fluid and debris. There are different compounds commercially available that may be used. Semen is deposited on top of this fluid and subjected to centrifugation. Motile sperm cells migrate to the bottom of the tube, which are used for IUI after further washing.

Q: How soon after an IUI can I go swimming?

A: Since the vagina doesn't open unless something pushes it, it is OK to swim shortly after your IUI . . . but because of how much one has invested in getting pregnant, it probably makes sense to wait 48 hours after your IUIs to go swimming.

Q: Can IUI work after tubal ligation (having "tubes tied")?

A: No. A tubal ligation is effective birth control because it prevents the sperm and egg from meeting. The process that leads to pregnancy is having an egg released from a follicle in the ovary and then beginning the journey to the uterus through the fallopian tube. Sperm will travel from the vagina, through the cervix, through the uterus, into the tube where fertilization occurs. IUI bypasses the need for the sperm to travel through the cervix, but that's it. It doesn't get the egg to the other side of the obstruction, so fertilization won't take place. The only way to get pregnant after tubal ligation is by having reversal surgery or an assisted reproduction technology that includes egg retrieval, such as in vitro fertilization (IVF).

Q: Can IUI be used for gender selection?

A: Yes, sperm can be washed or spun to increase the odds of having a male or female offspring.The techniques aren't 100 percent effective, but perhaps as high as almost 90 percent. There is usually greater success selecting boys. For more information, do a search on Google.


 PERSONAL EXPERIENCES WITH IUI

The process for IUI at my doctorÕs office was to call and schedule the procedure once LH surge was detected, or, if monitoring and doing hCG trigger, schedule the procedure based on the time of trigger. I did both methods and got pregnant from Clomid and IUI 24 hours after LH surge. I also did double IUIs based on hCG injection (22 and 46 hours after) and conceived and carried to.

We live about 20 minutes from the doctorÕs office, so we collected the sample at home, in a sterile cup. I kept my husbandÕs sample at body temperature by putting it in my bra, between my breasts, while we drove over. I'd run in, drop it off, and be told to return in an hour. When we got back, the nurse would usually show us a sample of the motile sperm under a microscope and hand us the loaded catheter with the sperm solution in it. We'd go into the procedure room and I would undress from the waist down. The doctor would come in, insert a speculum, then insert the catheter and inject the sperm I would continue to lay back on the motorized table and the doctor would incline the table a bit so my hips were elevated and ask us to come out after 15-20 minutes.

I did eight IUIs and most of them I actually didn't feel at all Š I even had to ask when the doctor was done, or I would be able to tell from the speculum being removed. My only uncomfortable one was my first, and it was probably the worst one as far as timing goes Š I think it was too early. The doctor used a tenaculum and I felt as if that pinched. Otherwise the only other discomfort was a quick contraction from a cold speculum, and the doctor made sure his new nurse knew what the warming tray was for after that.




The IUI is a simple procedure. My husband goes to the clinic about an hour before me and supplies his sample (they have private rooms with TVs, magazines, private bathrooms, etc. -- very helpful). When it's my turn, I go to an exam room, strip from the waist down, hop up on the exam table, and put a paper drape over my hips for privacy. The nurse comes in with paperwork and a test tube. The sample has been spun down, washed, etc. and is now just a small volume and is pink. The nurse shows me the test tube with my husband's name written on it and the paperwork listing the count, motility, forward progression, etc. of the sample and has me sign the paperwork. I lay down on the exam table, put my feet in the stirrups, and scoot my hips to the edge of the table. The nurse inserts a speculum and threads a catheter through my cervix. Sometimes my cervix is not positioned well, so the nurse might have to adjust the speculum or she has me press on my abdomen. Once the catheter is in, she injects the sample and waits a moment or two. She then removes the catheter and speculum, pulls the end of the table out and moves my feet off the stirrups and to the center of the table, knees still bent. She raises the middle of the table a little so my hips are tilted upward. Lastly, she runs through the procedure for the next couple of weeks (I usually do some kind of progesterone support). I stay on the table for 10 to 15 minutes and then get dressed and leave. The whole process takes a half-hour to 45 minutes, depending on how shy my cervix is being.




I and my husband had been trying to have a baby for 6 years when we finally went to seek help We were convenience that the problem was with me. We thought that most problems with infertility was due to the woman. My Gyn. suggested we have my husbands sperm checked first. Because it makes it a lot easier to narrow the problem that way. It was a great shock when we descovered that he had ZERO sperm count a very rare condition. The doctor told us that there might be a blockage and the only way to find out was to have a Testicle Biopsy first. They did a hormone check and it came back a little odd. So then we had the biopsy the conclusion was he was lacking any sperm producing cells other wise there was no way he could ever have his own biological child. We were devastated but at the same time happy that we finally knew what was wrong. We then persuaded to check out IUI's. At first my husband was unsure about his ability to raise a child that was not biologically his but decided it was our only hope because we could not afford to adopt. The fertility specialist we went to suggested I do a dye test to check my tubes before we persuaded with the IUI. That test showed that I had one partially blocked tube, So it was my turn for surgery after they repaired my tube we began the task of choosing a donor. Sense I didn't want my husband to feel left out at all I let him pick the Donor. after that we started on the ovulation kits . I had a really hard time trying to pen point my ovulation after two failed attempts I ask my doctor to put me on clomid that made it much easier to tell when I was ovulating. I missed my next insemination by a few hours so we were on our last try I took two test one in the morning and one in the evening so I would be sure not to miss it again. It worked I felt myself ovulate on the way to have my last IUI. Four weeks later I tested positive we were pregnant. It was really great for my husband as well. He felt so much involved he was with through out it all he was there through all the IUI's and through all my pregnancy. After 9 months I gave birth to a beautiful and healthy baby girl. Now she is 2 1/2 years old and we have never had any regrets she looks so much like both of us. We have so many people say how much she looks like her dad and we just smile. She has picked up a lot of his habits as well. We never even mention to each other about the donor but we are both very thankful for him. 6 months after the birth of my daughter I also became a donor as well. I wanted to help others achieve parenthood as well. Now I am considering becoming a surrogate as well. Don't give up it is all worth it over and over again if it works.




I just had this procedure done today, and my partner (girlfriend) and I are hoping we were successful. We are very excited. We have a 3-week wait before we will know anything, this will be the hardest. The emotions and adrenaline were running high this morning prior to the procedure. I, myself already have three beautiful children, therefore, there is no question regarding fertility. We love each other very much, and want to share our love with a child that is ours together. My children, who are of age to understand, are ecstatic and cannot wait. I found the procedure to be somewhat uncomfortable. My cervix was hard to reach and therefore, a tenaculum had to be used. This caused some mild cramping during and after the procedure. I did opt to rest and stay off my feet for the day. I did feel the specimen as it was inserted into the uterine cavity also. Overall, I have no regrets about the procedure thus far. If need be necessary, we will do this procedure again until we are successful.






 JOURNAL ABSTRACTS


J Assist Reprod Genet 13: 1, 56-63, Jan, 1996.
The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa.
Huang HY, Lee CL, Lai YM, Chang MY, Wang HS, Chang SY, Soong YK

Abstract
PURPOSE: The purpose of this study was to evaluate the relationship between the total motile sperm count and the success of IUI treatment cycles with postwashed husband spermatozoa in couples with infertility in a large patient population.
PATIENTS: When 939 couples underwent 1375 cycles of IUI with varying etiologies of infertility which included male factor, endometriosis, tubal factor, ovulatory dysfunction, uterine factor, cervical factor, and unexplained infertility, the results were 207 pregnancies.
RESULTS: The overall pregnancy rate per cycle was 15.1% (207/1375). The total motile sperm count were significantly increased in the pregnant group than the nonpregnant group (38.7 x 10(6) versus 28.6 x 10(6); P < 0.001). There was a trend toward an increased success rate with increased total motile sperm count. Significance was reached when the total motile sperm count exceeded 5 x 10(6). Life table analysis was performed and the curve representing a cumulative chance of pregnancy calculated from our data reached 72%.
CONCLUSIONS: Our findings suggest that a final postwashed total motile sperm count used for IUI may be considered predictive of the success for pregnancy and allow couples to be informed of the chances of success.

Fertil Steril 2001 Apr;75(4):661-8
Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization.
Van Voorhis BJ, Barnett M, Sparks AE, Syrop CH, Rosenthal G, Dawson J.
Department of Obstetrics & Gynecology, University of Iowa College of Medicine, Iowa, Iowa City 52242-1080, USA. brad-van-voorhis@uiowa.edu

OBJECTIVE: To determine prognostic factors for achieving a pregnancy with intrauterine insemination (IUI) and IVF. To compare the effectiveness and cost-effectiveness of IUI and IVF based on semen analysis results. DESIGN: Retrospective cohort study. SETTING: Academic university hospital-based infertility center. PATIENT(S): One thousand thirty-nine infertile couples undergoing 3,479 IUI cycles. Four hundred twenty-four infertile couples undergoing 551 IVF cycles.Intervention(s): IUI and IVF treatment. MAIN OUTCOME MEASURE(S): Multiple logistic regression analysis was used to assess the significance of prognostic factors including a woman's age, gravidity, duration of infertility, diagnoses, use of ovulation induction, and sperm parameters for predicting the outcomes of clinical pregnancy and live birth rate after the first cycle of IUI and IVF. The relative effectiveness and cost-effectiveness of these treatments were then determined based on sperm count results. RESULT(S): Female age, gravidity, and use of ovulation induction were all independent factors in predicting pregnancy after IUI. The average total motile sperm count in the ejaculate was also an important factor, with a threshold value of 10 million. For IVF, only female age was an important predictor for both clinical and ongoing pregnancy. When the average total motile sperm count was under 10 million, IVF with ICSI was more cost-effective than IUI in our clinic. CONCLUSION(S): An average total motile sperm count of 10 million may be a useful threshold value for decisions about treating a couple with IUI or IVF.

Fertil Steril 1999 Apr;71(4):684-9
Comparison of the sperm quality necessary for successful intrauterine insemination with World Health Organization threshold values for normal sperm.
Dickey RP, Pyrzak R, Lu PY, Taylor SN, Rye PH.
The Fertility Institute of New Orleans, and Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, New Orleans, USA.

OBJECTIVE: To compare World Health Organization threshold values for normal sperm with the initial sperm quality necessary for successful IUI. DESIGN: Retrospective study. SETTING: Private fertility clinic. PATIENT(S): One thousand eight hundred forty-one couples undergoing 4,056 cycles of IUI. INTERVENTION(S): Intrauterine insemination. MAIN OUTCOME MEASURE(S): Relation of initial sperm quality to fecundity. RESULT(S): Progressive motility and total motile sperm count were the initial sperm characteristics most closely related to pregnancy on discriminant analysis. The per-cycle pregnancy rate averaged 11.1% during the first three IUI cycles. Pregnancy rates were > or = 8.2% per cycle when the initial sperm values were a concentration of > or = 5 X 10(6)/mL, a total count of > or = 10 X 10(6), progressive motility of > or = 30%, or a total motile sperm count of > or = 5 x 10(6). Minimal increases in fecundity occurred when initial values were greater than these threshold levels. The lowest initial values that resulted in pregnancy were a concentration of 2 x 10(6)/mL, a total count of 5 x 10(6). motility of 17%, and a total motile sperm count of 1.6 X 10(6). Pregnancy rates were <3.6% when initial values were between the threshold levels and the lowest levels. CONCLUSION(S): The sperm quality that is necessary for successful IUI is lower than World Health Organization threshold values for normal sperm. Intrauterine insemination is effective therapy for male factor infertility when initial sperm motility is > or = 30% and the total motile sperm count is > or = 5 X 10(6). When initial values are lower, IUI has little chance of success.

Fertil Steril 1999 Mar;71(3):547-51
Advanced semen analysis: a simple screening test to predict intrauterine insemination success.
Branigan EF, Estes MA, Muller CH.
Bellingham In Vitro Fertilization and Infertility Center, Washington, USA.

OBJECTIVE: To determine if a simple screening test of sperm recovery through a density gradient preparation and sperm survival after a 24-hour incubation is predictive of IUI success. DESIGN: Prospective nonrandomized descriptive study. SETTING: Tertiary assisted reproductive technology center. PATIENT(S): Four hundred fourteen couples undergoing IUI for male factor and unexplained infertility. INTERVENTION(S): An advanced semen analysis, which consisted of a basic semen analysis, sperm processing through a density gradient preparation, and a 24-hour sperm incubation, was performed on all couples before beginning IUIs. MAIN OUTCOME MEASURE(S): Cumulative and per cycle pregnancy rates (PRs) were calculated for routine semen parameters, number of sperm processed through density gradient, and percent motile sperm after a 24-hour incubation. RESULT(S): None of the basic semen analysis parameters accurately predicted IUI success. When the processed total motile sperm available for insemination was > or = 10 x 10(6) and their 24-hour survival was > or = 70%, 89% (162 of 182) of couples achieved a pregnancy with a 21.4% (162 of 757) per cycle PR compared to a 2.8% (11 of 403) per cycle PR and 4.7% total PR when survival was <70%. With use of these cutoff values for the advanced semen analysis, the test had a sensitivity of 94% and specificity of 86%. CONCLUSION(S): The number of motile sperm available for insemination and especially their 24-hour survival are highly predictive of IUI success. This advanced semen analysis is an excellent screening test to evaluate couples considering IUI.

Hum Reprod 11: 9, 1892-6, Sep, 1996.
Prognostic indicators for intrauterine insemination (IUI): statistical model for IUI success
Tomlinson MJ, Amissah-Arthur JB, Thompson KA, Kasraie JL, Bentick B

Abstract
A retrospective analysis of 260 completed intrauterine insemination (IUI) cycles was used in an attempt to identify significant variables predictive of treatment success. Couples received a maximum of three IUI cycles for the treatment of anovulation, cervical factors or unexplained infertility. Male factor problems were largely excluded by pretreatment screening. The overall pregnancy rate was 19.6% per completed cycle, the miscarriage rate 15.6%, the multiple pregnancy rate 23.5% and the cancellation rate 19%. Logistic regression identified four significant IUI variables [follicle number (P < 0.005), endometrial thickness (P < 0.005), duration of infertility (P < 0.01) and progressive motility (P < 0.05)] which were the most predictive of IUI success. The chance of conceiving when only one follicle was produced was only 7.6%, whereas with two follicles this chance increased to 26%. These variables were incorporated into a statistical model to allow the prediction of the chance of success in subsequent cycles. We conclude that careful patient selection criteria coupled with successful ovarian stimulation is the model for IUI success.

J Med Assoc Thai 76: 8, 415-23, Aug, 1993.
Two years' experience of intrauterine insemination for the treatment of infertility
Rojanasakul A, Suchartwatnachai C, Choktanasiri W, Wongkularb A, Hansinlawat P, Chinsomboon S

Abstract
The result of a two year (1990-1991) trial of IUI is presented. Discontinuous Percoll-gradient centrifugation technic was used for motile sperm separation. In 174 couples with 610 treatment cycles, there were 49 clinical pregnancies. The pregnancy per patient was 28 per cent and the pregnancy per cycle was 8 per cent. Cycle fecundity by various factors which possibly influence the outcome were assessed. The success rate appeared to be higher in the young female age group, short duration of infertility, secondary infertility, unexplained infertility, a higher number of motile sperm inseminated and dual insemination in a cycle.

J Reprod Med 41: 9, 658-64, Sep, 1996.
Treating infertility. Controlled ovarian hyperstimulation using human menopausal gonadotropin in combination with intrauterine insemination
Vollenhoven B, Selub M, Davidson O, Lefkow H, Henault M, Serpa N, Hung T

Address: Division of Reproductive Endocrinology and Infertility University of Miami School of Medicine Florida USA.
Abstract
OBJECTIVE: To determine the effectiveness of human menopausal gonadotropin (hMG) with intrauterine insemination (IUI) for the treatment of various causes of infertility and to identify prognostic factors for the success of this treatment. STUDY
DESIGN: Retrospective chart analysis.
RESULTS: Of the 271 cycles initiated, 247 were completed in 104 couples, and analysis of these cycles showed that the overall cycle fecundity rate was 10% and the pregnancy rate 22%. The miscarriage rate was 8% and the ectopic pregnancy rate 4%. The multiple pregnancy rate was 29%. For the various causes of infertility, we found that the cycle fecundity rate was 7% for male factor, 11% for oligoovulation, 8% for tubal/pelvic factor, 13% for minimal endometriosis, 18% for mild endometriosis, 17% for moderate endometriosis, 3% for women aged > or = 40 years, 75% for myoma, and 7% for idiopathic infertility. We also found that one IUI timed at 36-48 hours was as effective as two IUIs timed at 18-24 and 36-48 hours after human chorionic gonadotropin (hCG) administration. Poor prognostic factors that were elicited from this study were: (1) failure of pregnancy in three cycles of treatment, (2) female age > or = 40 years, (3) requirement of > 300 IU of hMG daily, and (4) presence of more than eight mature follicles at the time of hCG administration.
CONCLUSION: HMC and IUI are effective treatment of some causes of infertility.

Andrologia 27: 4, 217-21, Jul-Aug, 1995.
The effective cumulative pregnancy rate of different modes of treatment of male infertility
Comhaire F, Milingos S, Liapi A, Gordts S, Campo R, Depypere H, Dhont M, Schoonjans F

Abstract
The clinical efficacy of conventional and advanced methods of treatment was assessed in 814 couples with infertility due to a male factor. The monthly and effective cumulative rate of ongoing or term pregnancies was calculated during 4712 couple-months. Treatment of varicocele by transcatheter embolization, resulting in 3.9% pregnancies per cycle and an effective cumulative pregnancy rate of 41% after 1 year, is more effective than counselling and timed intercourse (9% pregnancies after 12 months). Intrauterine insemination (IUI) of washed spermatozoa produced 17% pregnancies in the initial 4 months, but the success rate of the subsequent cycles (1.7% per cycle) was not different from that of the controls. In vitro fertilization (IVF) resulted in 16% pregnancies per attempt, but the effective cumulative pregnancy rate was only 31% in 12 months due to the long interval between treatment attempts and the high drop-out rate. With subzonal microinjection of sperm, the fertilization rate was higher (71%) than with regular IVF (29%) but both the pregnancy rate per attempt (9%) and the effective cumulative pregnancy rate (17% after 12 months) were low. The 10th percentile of sperm characteristics (cut-off values) of successful cases showed intrauterine insemination to be advantageous in cases with a lower percentage of spermatozoa with progressive motility (9%) than in the controls (15%). The cut-off value of sperm morphology in IVF (4%) is lower than that of IUI (8%) and of the controls (9%), but higher than that of subzonal insemination (1%). Treatment strategy must be defined selecting or combining conventional and assisted reproductive technology for each individual couple with male factor infertility.
Ripps BA, Minhas BS, Carson SA, Buster JE, Intrauterine insemination in fertile women delivers larger number of sperm to the peritoneal fluid than intracervical insemination., Fertil Steril 61: 2, 398-400, Feb, 1994. Address: Department of Obstetrics and Gynecology University of Tennessee-Memphis. Abstract Randomized IUI or intracervical insemination of eight fertile women with 50 x 10(6) sperm was performed to determine whether IUI delivers more spermatozoa to the peritoneal cavity. After IUI (n = 4), 2,053 to 29,450 sperm were recovered in the PF at laparoscopy. No sperm were found in the PF after intracervical insemination (n = 4). After IUI, CM contained 1.0 x 10(6) to 57.0 x 10(6) sperm/mL; after intracervical insemination, 0 to 1.2 x 10(3) sperm/mL were seen. One therapeutic mechanism for IUI is delivery of larger sperm numbers to the fertilization site by rapid (4 hours) transport. In addition, there is greater retrograde colonization of CM that may result in sustained release of sperm.

J Reprod Med 2000 Nov;45(11):917-22
Sperm-preparation techniques for men with normal and abnormal semen analysis. A comparison.
Erel CT, Senturk LM, Irez T, Ercan L, Elter K, Colgar U, Ertungealp E
Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey. tamererel@superonline.com

OBJECTIVE: To compare two commonly used sperm-preparation techniques, density gradient centrifugation and swim-up procedures, with respect to their effects on acrosome reaction (AR), hypoosmotic swelling (HOS) and nuclear maturity in men with abnormal and normal semen analyses. STUDY DESIGN: In accordance with World Health Organization criteria, 23 men with abnormal (group I) and 20 men with normal (group II) semen analyses were included in a prospective, controlled study. Each semen specimen was divided into aliquots in order to assess AR, HOS and nuclear maturity, determined with acridine orange staining, in both raw and processed semen samples using the density gradient centrifugation and swim-up techniques. RESULTS: Initial semen samples in group I revealed diminished AR, HOS and nuclear maturity rates in comparison to those in group II. In group I, density gradient centrifugation improved AR, HOS and nuclear maturity rates more than did swim-up. However, in group II it improved only the AR; HOS rates were better than with swim-up. There was a significant positive correlation between sperm concentration and HOS rate in raw semen samples from group I. In the same group, motility and morphology correlated with the nuclear maturity rate but not with AR and HOS rates. Semen samples with better motility (> 20%) or morphology (> 25%) showed better nuclear maturity rates (> 50%) in men with abnormal semen analyses. Motility had a sensitivity of 77% and specificity of 90% in predicting nuclear maturity. Morphology had similar sensitivity but lower specificity (70%). CONCLUSION: Density gradient centrifugation is superior to the swim-up technique in improving AR, HOS and nuclear maturity rates in men with abnormal semen analyses. However, when only nuclear maturity rate is taken into account, the swim-up technique seems to be sufficient for selecting spermatozoa in men with normal semen analyses. The nuclear maturity rate also correlates with sperm morphology and motility.

J Assist Reprod Genet 2000 May;17(5):245-52
The effect of patient and semen characteristics on live birth rates following intrauterine insemination: a retrospective study.
Hendin BN, Falcone T, Hallak J, Nelson DR, Vemullapalli S, Goldberg J, Thomas AJ Jr, Agarwal A.
Andrology Research and Clinical Laboratories, Cleveland Clinic Foundation, Ohio 44195, USA.

PURPOSE: To identify characteristics of female patients and of semen that were associated with live birth following intrauterine insemination (IUI). METHODS: Retrospective review of medical and laboratory results from 533 women who underwent IUI with partner's sperm from 1993 through 1995. RESULTS: Among 1728 cycles, 116 (6.7%) resulted in live deliveries. Among the 38 patient and semen variables analyzed, only 3 were associated with successful IUI outcome: female age < 37.7 years at the time of treatment (P = 0.02); the absence of any corrective pelvic surgery (P < 0.001); and postwash sperm motility (P = 0.006). Couples with none of these three risk factors achieved per-cycle pregnancy rates of 12.4%. Women with two risk factors (age and pelvic surgery) achieved per-cycle pregnancy rates of 4.6% when sperm had good postwash motility. No pregnancies were achieved when low postwash motility was combined with any other risk factor. CONCLUSIONS: Advanced female age, poor postwash sperm motility, and a history of corrective pelvic surgery are significant risk factors for poor IUI success rates. Poor postwash sperm motility in combination with either of these other two risk factors resulted in no successful pregnancies.

Hum Reprod 10: 7, 1765-74, Jul, 1995.
Strategies in frozen donor semen procreation
Le Lannou D, Gastard E, Guivarch A, Laurent MC, Poulain P

Abstract
Data were analysed from 710 couples who had been assessed to determine the effectiveness and the drawbacks of three different methods of insemination using frozen donor semen. Intracervical insemination (ICI) was the first method used when the women had no tubal disorder: 255 pregnancies were achieved in a total of 2558 cycles (10%). Intrauterine insemination (IUI) associated with ovarian stimulation resulted in 152 pregnancies over 966 cycles (16%). In-vitro fertilization (IVF) was proposed after approximately 12 insemination failures using either of the other methods or when the initial gynaecological examination had revealed abnormalities such as tubal occlusions; 48 pregnancies were obtained in 262 cycles (18.3%). The pregnancy rate using ICI was significantly higher when two inseminations were performed per cycle, compared with one insemination per cycle (12.3 versus 7%, P < 0.001). The number of motile spermatozoa per straw was correlated with the pregnancy rate when using ICI, rising from 9% with < 4 x 10(6) motile spermatozoa to 13.8% with 4-8 x 10(6) and 17.2% with > 8 x 10(6). No relationship was found between the number of motile spermatozoa and the pregnancy rate using IUI and IVF. The incidence of primary ovulatory disorder was higher among women whose husbands were oligozoospermic than among those whose husbands were azoospermic (19 versus 9%, P < 0.01), but ovarian stimulation improved the fecundity of subfertile women. The outcome of pregnancies was also analysed for the three methods. From these data, strategic plans have been proposed to maximize the pregnancy rate for women undergoing therapeutic donor insemination with frozen semen.

Hum Reprod 1996 Apr;11(4):732-6
Intrauterine insemination: evaluation of the results according to the woman's age, sperm quality, total sperm count per insemination and life table analysis.
Campana A, Sakkas D, Stalberg A, Bianchi PG, Comte I, Pache T, Walker D

We report on 332 infertile couples who underwent 1115 cycles of intrauterine insemination (IUI) with washed husband's semen. The indication for IUI was an abnormal post-coital test due to either a male or cervical infertility factor. The mean number of IUI cycles per patients was 3.4, the overall pregnancy rate 18.7%, and the pregnancy rate per cycle 5.6%. The cumulative pregnancy rate calculated by life table analysis showed that 16.0% of pregnancies occurred in the first three treatment cycles, while the cumulative pregnancy rate was 26.9% by the sixth cycle. The outcome of the therapy was adversely affected if the woman's age was > 39 years and/or total motile sperm count per insemination was < 1 x 10(6). No pregnancy occurred in women older than 44 years or in cases with a total motile sperm count before semen preparation of < 1 x 10(6).

Arch Androl 35: 2, 135-41, Sep-Oct, 1995. Intrauterine insemination for cervical and male factor without superovulation
Check JH, Bollendorf A, Zaccardo M, Lurie D, Vetter B

Abstract
Intrauterine insemination (IUI) has been used for the treatment of various causes of infertility, including unexplained infertility, male factor, and cervical factor. Some centers frequently use superovulation combined with IUI. The study presented herein attempted to evaluate the efficacy of IUI without superovulation in cases where all causes of infertility other than cervical or male factors have been eliminated. However, in the case of poor or absent cervical mucus, the use of controlled ovarian hyperstimulation (COH) may obscure the actual importance of the IUI, since it is possible that the poor cervical mucus is related to poor timing, inadequate follicular maturation, or low estradiol levels, which if corrected will obviate the need for IUI. In this study IUI was targeted for 36-40 h following the sera luteinizing hormone surge. A total of 108 patients were enrolled in this study: 47 with male factor, 61 with cervical factor. Patients were followed for a maximum of three cycles unless a pregnancy occurred within 3 months of treatment. Comparison of pregnancy rates (PRs) were based on diagnosis. The cumulative PRs per cycle for each of the three cycles studied were as follows: cervical factor--19.7, 36.8, and 36.8%; male factor--12.8, 29.3, and 38.3%. Thus, PRs were comparable for both groups after three treatment cycles. These data demonstrate that IUI is an effective therapy for cervical and/or male factor, even without superovulation.

Arch Androl 35: 1, 71-7, Jul-Aug, 1995.
Higher pregnancy rates following treatment of cervical factor with intrauterine insemination without superovulation versus intercourse: the importance of a well-timed postcoital test for infertility
Check JH, Spirito P

Abstract
A randomized study comparing the efficacy of timed intrauterine insemination (IUI) without hyperstimulation to sexual intercourse was performed in women with cervical factor infertility. Among the strict requirements for inclusion in the study were a normal semen analysis in the male partner, as well as the failure to demonstrate any sperm with progressive forward motion in a postcoital test performed 8-12 h after intercourse at the time of a mature follicle. All other infertility factors were negative. The data demonstrated a statistically significant fecundity rate at 1 month when IUI was compared to intercourse (21.2 vs. 3.9%). These data suggest that carefully timed IUI in nonhyperstimulated cycles is an effective treatment for cervical factor infertility.

Fertil Steril 63: 2, 295-8, Feb, 1995.
Does intrauterine insemination offer an advantage to cervical cap insemination in a donor insemination program?
Williams DB, Moley KH, Cholewa C, Odem RR, Willand J, Gast MJ

Abstract
OBJECTIVE: To compare pregnancy outcome after IUI versus cervical cap insemination in a donor insemination program.
DESIGN: A randomized prospective clinical trial in which patients were alternately inseminated with cryopreserved human semen using either IUI or cervical cap insemination methods. SETTING: The donor insemination program at Washington University School of Medicine. PATIENTS: Forty-two women with either isolated male factor or male factor plus corrected ovulatory dysfunction using clomiphene citrate underwent 141 cycles of donor insemination. MAIN OUTCOME MEASURES: Clinical pregnancy rates (PRs) defined as a viable intrauterine gestation > 12 weeks or delivered were compared between groups using the chi 2 test.
RESULTS: Clinical PRs were significantly higher in the IUI group (16.4%) compared with the cervical cap insemination group (5.9%). The spontaneous abortion rates were similar between the IUI (1.4%) and cervical cap insemination groups (4.4%).

Gynecol Obstet Invest 38: 1, 57-9, , 1994.
Evaluation of whether using hCG to stimulate oocyte release helps or decreases pregnancy rates following intrauterine insemination
Check JH, Peymer M, Zaccardo M

Abstract
The study's objective was to determine if using human chorionic gonadotropin (hCG) as a timing method for intrauterine insemination (IUI) in patients who make mature follicles but have cervical factor problems has a negative effect on pregnancy rates (PRs) (possibly by releasing an immature oocyte), or increases the rate of luteinized unruptured follicles (LUF). Patients were offered hCG or natural release after an explanation of the theoretical advantages and disadvantages. Intrauterine insemination was performed 36-40 h after hCG; timing of IUI with hCG was based on day of luteinizing hormone (LH) surge modified by serum progesterone (P). Incidence of LUF in those taking hCG-5/116 (4.3%); 0/33 without hCG. Pregnancies-24/116 (20%) with hCG; 3/30 (10%) without hCG. No statistical differences in these rates were found. Thus, using hCG for more convenient timing for IUI in nonsuperovulated cycles does not decrease the PR or cause a high incidence of LUF.

Hum Reprod 9: 2, 330-3, Feb, 1994.
The effect of halving the standard dose of cryopreserved semen for donor insemination: a controlled study of conception rates
Corrigan E, McLaughlin EA, Coulson C, Ford WC, Hull MG

Abstract
Employing a common standard technique of intra-cervical insemination from straws of cryopreserved donor semen, a volume of 0.25 ml of 0.5 ml was inseminated in alternate cycles to determine if the lower volume could be used without a decrease in the conception rate. A total of 177 women were recruited and received a median of four cycles of treatment. Of these, 90 women became pregnant, 47 with 0.5 ml and 43 with 0.25 ml inseminations. The conception rates were identical for both volumes in the first nine cycles of treatment and the cumulative rates were 57.7 and 59.3%, respectively. Subsequently more pregnancies were achieved with 0.5 ml than 0.25 ml semen (nine pregnancies in 73 further cycles versus three pregnancies in 68 cycles, respectively), although the difference was not statistically significant. There were no significant differences in the women's ages, luteinizing hormone, follicle stimulating hormone, progesterone, mucus quality, mucus pH, parity or partner's diagnosis between those women who became pregnant and those who failed to conceive with either insemination dose. We conclude that the volume of semen inseminated into the cervical canal without a cervical cap can be decreased to 0.25 ml without an adverse effect on the conception rate at least in the first 9 months of treatment. This will allow more effective use to be made of valuable screened and quarantined cryopreserved semen.

Hum Reprod 11: 9, 1892-6, Sep, 1996.
Prognostic indicators for intrauterine insemination (IUI): statistical model for IUI success
Tomlinson MJ, Amissah-Arthur JB, Thompson KA, Kasraie JL, Bentick B

Abstract
A retrospective analysis of 260 completed intrauterine insemination (IUI) cycles was used in an attempt to identify significant variables predictive of treatment success. Couples received a maximum of three IUI cycles for the treatment of anovulation, cervical factors or unexplained infertility. Male factor problems were largely excluded by pretreatment screening. The overall pregnancy rate was 19.6% per completed cycle, the miscarriage rate 15.6%, the multiple pregnancy rate 23.5% and the cancellation rate 19%. Logistic regression identified four significant IUI variables [follicle number (P < 0.005), endometrial thickness (P < 0.005), duration of infertility (P < 0.01) and progressive motility (P < 0.05)] which were the most predictive of IUI success. The chance of conceiving when only one follicle was produced was only 7.6%, whereas with two follicles this chance increased to 26%. These variables were incorporated into a statistical model to allow the prediction of the chance of success in subsequent cycles. We conclude that careful patient selection criteria coupled with successful ovarian stimulation is the model for IUI success.

Fertil Steril 64: 3, 505-10, Sep, 1995.
A new system for fallopian tube sperm perfusion leads to pregnancy rates twice as high as standard intrauterine insemination
Fanchin R, Olivennes F, Righini C, Hazout A, Schwab B, Frydman R

Abstract
OBJECTIVE: To evaluate the relative efficacy of a new system for fallopian tube sperm perfusion in comparison with standard IUI in controlled ovarian hyperstimulation (COH) cycles.
DESIGN: Prospective randomized trial. SETTING: Ovulation induction program of a tertiary outpatient care center, Hopital Antoine Beclere, Clamart, France. PATIENTS: We studied 74 infertile women aged 20 to 38 years undergoing 100 cycles of COH from December 1993 to May 1994 only excluding cases of age > 38 years, obstructed or severely damaged fallopian tubes, E2 levels per mature follicle < 250 pg/mL (conversion factor to SI unit, 3.671) on the day of hCG administration, spontaneous LH surge, and cases of marked sperm abnormalities. INTERVENTIONS: Controlled ovarian hyperstimulation was achieved using three types of ovarian stimulation protocols: clomiphene citrate (CC) and hMG (n = 35). hMG alone (n = 35) or GnRH agonist and FSH and hMG (n = 30). Thirty-six hours after hCG administration, patients were assigned randomly to either IUI (group A, n = 50) or fallopian tube sperm perfusion (group B, n = 50). Intrauterine insemination was performed with 0.2 mL of sperm suspension according to a standard technique. Fallopian tube sperm perfusion was performed using a simple and reliable system that ensures a good cervical seal and allows to a pressurized injection of 4 mL of sperm suspension. MAIN OUTCOME MEASURES: Feasibility of the fallopian tube sperm perfusion method, clinical pregnancy (presence of gestational sac with heart beats at 6 weeks of amenorrhea), and ongoing pregnancy rates (PRs) (> 12 weeks of amenorrhea), incidence of complications (multiple pregnancies and ovarian hyperstimulation syndrome [OHSS]).
RESULTS: Overall, the new fallopian tube sperm perfusion system was simple to handle and well tolerated by patients. In group A, we observed 10 clinical pregnancies (20% per cycle) of which 7 were ongoing (14%). In group B, 20 clinical pregnancies (40% per cycle) of which 17 ongoing pregnancies (34%) were obtained. These differences were statistically significant. The prevalence of twin and three or more sac pregnancies was similar in the two groups (3/10 and 0/10, respectively, in group A, and 5/20 and 2/20, respectively, in group B). No case of moderate or severe OHSS was observed in this series.
CONCLUSIONS: Our results indicate that the new system for fallopian tube sperm perfusion is not only simple and reliable but also may lead to PRs twice as high as standard IUI in COH cycles.

N Engl J Med 1999 Jun 10;340(23):1796-9
Time of implantation of the conceptus and loss of pregnancy.
Wilcox AJ, Baird DD, Weinberg CR

BACKGROUND: Implantation of the conceptus is a key step in pregnancy, but little is known about the time of implantation or the relation between the time of implantation and the outcome of pregnancy. METHODS: We collected daily urine samples for up to six months from 221 women attempting to conceive after ceasing to use contraception. Ovulation was identified on the basis of the ratio of urinary estrogen metabolites to progesterone metabolites, which changes rapidly with luteinization of the ovarian follicle. The time of implantation was defined by the appearance of chorionic gonadotropin in maternal urine. RESULTS: There were 199 conceptions, for 95 percent of which (189) we had sufficient data for analysis. Of these 189 pregnancies, 141 (75 percent) lasted at least six weeks past the last menstrual period, and the remaining 48 pregnancies (25 percent) ended in early loss. Among the pregnancies that lasted six weeks or more, the first appearance of chorionic gonadotropin occurred 6 to 12 days after ovulation; 118 women (84 percent) had implantation on day 8, 9, or 10. The risk of early pregnancy loss increased with later implantation (P<0.001). Among the 102 conceptuses that implanted by the ninth day, 13 percent ended in early loss. This proportion rose to 26 percent with implantation on day 10, to 52 percent on day 11, and to 82 percent after day 11. CONCLUSIONS: In most successful human pregnancies, the conceptus implants 8 to 10 days after ovulation. The risk of early pregnancy loss increases with later implantation.

Gynecol Obstet Invest 1999;48(1):7-13
A controlled study for gender selection using swim-up separation. Khatamee MA, Horn SR, Weseley A, Farooq T, Jaffe SB, Jewelewicz R.
New York University School of Medicine, New York, N.Y., USA. frfbaby@msn.com

OBJECTIVE: To evaluate the success for gender selection using a sample of semen separated by a modified swim-up technique. DESIGN: We retrospectively compared the gender outcome of two treatments (A and B) for either a male or female offspring with those who conceived spontaneously. SETTING: Private practice of one author (M. A.K.). PATIENTS, PARTICIPANTS: The treatment groups consisted of 52 total pregnancies for couples who conceived by the separation technique. Of these 52 participants, 15 desired a female offspring and were placed into treatment A and 37 desired a male offspring and were placed into treatment B. The control groups consisted of 162 women who were presented with initial consultation for gender selection and conceived spontaneously. Control group A consisted of 80 women who initially chose a female offspring, and control group B consisted of 82 participants who initially chose a male. INTERVENTIONS: In treatment group A, one timed intrauterine insemination (IUI) was carried out with the bottom 0.5 ml of the separated semen on cycle days 12-14, when the follicle was 18-22 mm. Patients in this group were also administered clomiphene citrate and human chorionic gonadotropin. In treatment group B, one timed IUI was done with the top 0.5 ml of the separated semen, when the follicle was 18-22 mm. MAIN OUTCOME MEASURE: The gender outcome of the pregnancies of two treatment and control groups was evaluated based on the known desired gender. RESULTS: The success rate for conceiving a female child after intervention (treatment group A) was 86.7% effective (p = 0.002) as compared to the control group A. Couples seeking a male child (treatment group B) were 89.2% effective (p = 0.0002) as compared to the control group B. CONCLUSIONS: This study reveals that the modified swim-up method with additional monitoring results in statistically significant gender preselection.


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