Fertility and Sterility, The Official Journal of the American Society of Reproductive Medicine

Volume 78, Issue 6, Page 1347 (December 2002)

Timing of intrauterine insemination

Jaroslav J. Marik M.D.
Received 20 Feburary 2002;


To the Editor:
I read with interest the article by Pryor et al. (1). I would like to discuss some potential problems with the study. Women in protocol 1 did not have ultrasonographic determination of preovulatory or postovulatory follicular development. Ovulation predictor kits are unreliable. Basal body temperature can provide vague confirmation only if it increases significantly within 48 hours after the supposed LH surge. If ovulation occurred and the luteal phase was normal, one would expect a menstrual period 15 to 16 days after the LH surge. Because no such information was provided, we do not know whether the patients ovulated.

On protocols 2 and 3, ultrasonography demonstrated the development of the follicles. It is not clear whether the estradiol range of 200 to 300 pg/mL for “each follicle” includes only follicles 15 mm to 20 mm or smaller ones as well. If hCG was administered when the “dominant follicle” was only 15 mm, it was probably administered before the follicle became receptive to ovulation stimulus and, consequently, ovulation probably did not occur. Besides pregnancy, the next best evidence of ovulation is ultrasonographic disappearance of the follicle 48 to 72 hours after administration of hCG. The incidence of a luteinized unruptured follicle (2) increases if hCG is administered too early.

The number of inseminations listed in Table 1 is 1 to 5. There is no indication whether only one insemination per cycle was done or whether the inseminations were repeated. For example, patient 1 underwent eight inseminations under protocol 1 and 2 and never had postovulatory ultrasonography or measurement of progesterone levels.

The timing of insemination disregards the universally accepted recommendations for IVF retrieval of the oocytes 36 hours after hCG administration (3). The interval of 32 to 34 hours seems to be ill advised.

If ovulation occurred in protocols 2 and 3 in response to hCG administration or a spontaneous LH surge, sperm introduced 32 to 34 hours after hCG administration probably did not survive 6 hours to produce the same results as insemination done 38 to 40 hours after hCG injection. An in vitro test of sperm survival would be of interest.

Four patients who did not conceive under protocol 3 had IVF, of whom two became pregnant. Table 1 shows three patients treated with ICSI, all of whom became pregnant. No information is provided on the fourth IVF patient, and no explanation is offered on to why the paper reports only two IVF pregnancies when three patients underwent successful ICSI.

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References

1. Pryor JL, Kuneck PH, Blatz SM, Throp C, Cornwell CE, Carrell DT. Delayed timing of intrauterine insemination results in a significantly improved pregnancy rate in female partners of quadriplegic men. Fertil Steril. 2001;76:1130-1135 Abstract | Full Text | PDF (62 KB) | MEDLINE | CrossRef
2. Marik JJ, Hulka JF. Luteinized unruptured follicle: a subtle cause of infertility. Fertil Steril. 1978;29:270-274 MEDLINE

3. Pauserstein CJ, Eddy CA, Croxatto HD, Hess R, Siler-Khodr TM, Croxatto HB. Temporal relationship of estrogen, progesterone and luteinizing hormonal levels to ovulation in women and infrahuman primates. Am J Obstet Gyncol. 1978;130:876-882

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a Tyler Medical Clinic, Los Angeles, California, USA
© 2002 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.