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Artificial Insemination in the Human* JOHN A BOARD, M.D. Professor of Obstetrics and Gynecology, Medical College of Virginia, Richmond, Virginia The idea that impregnation might occur with­ tion using the husband's semen has not resulted out coitus has aroused interest since ancient times. in pregnancy. In the second century AD., there was recorded When Rh incompatibility has already resulted a hypothetical discussion concerning a woman who in the birth of an erythroblastotic infant, and partic­ had been inseminated by semen previously de­ ularly when the husband is homozygous Rh posi­ posited in the bath water in which she bathed. In tive, insemination of the wife with semen from an 1322, an Arab used artificial insemination with Rh negative donor will prevent the recurrence of horses. A wad of wool was introduced into the erythroblastosis. Fortunately, the availability of vagina of a mare and left overnight. It was then Rho (D) immune globulin (human) has dramati­ held over the nostrils of a stallion, and with this cally reduced the number of Rh negative women stimulus the stallion ejaculated on a cloth held who have been sensitized, and this is becoming in readiness. The ejaculated material was then a less common indication for artificial insemination. introduced into the vagina of a mare, which foaled When the husband has a family history of after the appropriate length of time. genetic disease which makes fatherhood inadvis­ During the 1700's, isolated instances of hu­ able or when the couple has had affected offspring man artificial insemination were reported, almost indicating abnormal recessive genes with the likeli­ always using the husband's semen. In the United hood of producing serious congenital defects in States, human artificial insemination using donor's subsequent pregnancies, artificial insemination with semen was first practiced by Dr. Robert L Dick­ donor's semen may be used. Examples of this are inson in 1890. His work was initially done in Tay-Sachs disease, and cases where both husband secrecy, although subsequently he did much to and wife have AS hemoglobin. train others in the technique and to gain public The presence of agglutinating antibodies acceptance of the procedure. against the husband's sperm but not against donor sperm may occur in a woman with prolonged and Artificial Insemination Using Donor's Sperm. otherwise unexplained infertility · (Dukes and The most common indication for artificial insemina­ Franklin, 1968). The test for this is not an absolute tion using donor's semen is sterility of the hus­ one, as some women who agglutinate their husband's band. This may be manifest as total azoospermia sperm have been of high fertility. In a situation or severe oligospermia, demonstrated on repeated where antibodies are present, in some cases the examinations. The husband should, of course, have use of condom for a time to protect against repeated a thorough medical and urologic examination to be exposure to antigen will result in disappearance of certain that his sterility is not secondary to a treat­ agglutinating antibodies followed by pregnancy. able condition. Considerable judgment is required Where condom therapy fails, artificial insemination to decide when to treat cases of oligospermia this using donor's sperm which are not agglutinated way. In most instances, this is done when ap­ by the wife's antibodies may be used. The ABO propriate medical therapy has failed to improve relationship to infertility is even more unclear, the quality of the ejaculate and artificial insemina- although there seems to be a statistically significant effect when an ABO incompatibility exists and the husband is a "secretor," in which case donor * Presented at the 43rd Annual McGuire Lecture Series, December 2, 1971, at the Medical College of Vir­ semen from a male of appropriate blood type may ginia, Richmond. result in pregnancy. MCV QUARTERLY .8(1): 13-18, 1972 13 14 BOARD: ARTIFICIAL INSEMINATION IN THE HUMAN Donor insemination has special emotional ovary hyperemia test to predict the time of ovula­ connotations, and both husband and wife should tion. This test is said to be capable of determining be aware of the possible emotional effect of the the time of ovulation within six to twelve hours procedure on their future relationship. Both hus­ (Farris, 1948). More recently, the use of rapid band and wife should be reasonably well-adjusted radio immunoassay procedures for LH, in order to individuals, and they should feel that they have a detect the pre-ovulatory LH peak, has been sug­ stable marriage. It is extremely important not to do gested as an aid in timing the deposition of sperm, this procedure to "save the marriage" as this is whether it be by natural or artificial means. far too big a job to place upon the shoulders of an Kleegman has found there is a sex differentia­ individual who weighs only seven pounds or so. tion in infants related to the time of artificial in­ Both husband and wife should have a desire for semination and ovulation (Kleegman, 1967). She children, and the man should not feel that he is utilized basal temperatures somewhat to determine being coerced into this procedure in order to pro­ the time of ovulation, but put more emphasis on vide fulfillment of his wife's maternal instincts. mittelschmerz (sometimes elicited with a "bounce In most cases, it is advisable to wait for a while test") and mucorrhea. Using this as evidence of after the husband has found out about his sterility ovulation, she has noted that exposure 2-24 hours problem before carrying out artificial insemination before ovulation was more likely to result in a because he will need time to recover from the male infant and that exposure 36 or more hours shock that such news is to every man. When it has before ovulation or 2-8 hours after ovulation was been decided to use insemination with donor's se­ more likely to result in a female infant. She was men, both husband and wife should sign a consent able to predict sex in 77% of cases utilizing this form. method. She also noted that men who have severe In the past when there was no shortage of oligospermia but whose wives have still become babies for adoption, we did not encourage artificial pregnant, have a preponderance of female chil­ insemination, but did it only when the couple dren and that rhythm failures with conception oc­ specifically requested it, feeling that adoption curring on cycle days 4 to 7 usually result in solved two social problems, that is, providing a fam­ female infants. Certain other investigators have been ily to the child and a child to the family. With the unable to reduplicate this accuracy in prediction recent increase in therapeutic abortions, the supply (Cohen, 1966), but in fairness to Kleegman, it of infants for possible adoption has so dwindled should be noted that most have used only basal that artificial insemination is more often mentioned temperature as an index of ovulation and have not to the couple as a solution to their infertility or relied on mittelschmerz or cervical mucus changes. genetic problems. Aside from suggesting the avail­ Most of the donors which we use are either ability of donor's semen to such couples, we do medical students or house officers, who are married not try to encourage this where either partner and are already fathers of normal children. These expresses any hesitancy. men report no knowledge of hereditary disease A fertility investigation is done for each couple and are of above average intelligence, If the wife seeking artificial insemination, if this has not been has Rh negative blood, an Rh negative donor is previously accomplished. As a minimum, patency also chosen. We do not make any effort to match of the wife's fallopian tubes is established by a blood types otherwise, because any good laboratory Rubin's test using carbon dioxide, and an endo­ could readily establish the fact that the woman's metrial biopsy is done to confirm ovulation. The husband is not the father of the child by utilizing patient is also instructed to begin keeping basal other blood groups such as the MN, Kidd, Duffy, temperature charts, in order that the most optimal and Kell which establish a "fingerprint." We make time for insemination may be selected. After re­ an effort to match donor to husband by somatic viewing temperature charts for several months, a type, skin, hair, and eye coloration, but this is not day is selected. This day will likely be one or two always possible. We would not, however, use a days prior to the basal temperature rise. It has short, black-haired donor of Mediterranean origin been our practice to perform insemination once a for a couple where both husband and wife were tall, month for the first three months, and if pregnancy blonde, and fair-skinned. has not occurred in this time, then to perform sev­ Our experience has been entirely with fresh eral at two-day intervals until the temperature rise semen, and the donor is instructed to obtain a has definitely occurred. Some physicians use a rat specimen by masturbation into a clean glass con- BOARD: ARTIFICIAL INSEMINATION IN THE HUMAN 15 tainer shortly before the couple's appointment. The By this time, active sperm should be well on their donor then delivers the semen to a designated way up the female reproductive tract and any lethal point, and it is then transferred to the patient area activity in the seminal plasma would be of no con­ by other personnel. It is important that the donor sequence. not deliver the specimen himself to this office, in When a woman has somewhat irregular ovula­ order to exclude the possibility that he and the tion, she is given an injection of 5000 international recipients might meet.

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