Introduction

It is estimated that 10-15% of all couples in Europe are involuntarily childless and desire treatment.

Doctors typically consider artificial insemination methods when a couple has not become pregnant within a year despite regular sexual intercourse.

Methods of artificial insemination

There are basically 4 different types of artificial insemination. Which one makes the most sense and is the most promising depends on the personal situation and the causes of infertility. Therefore, careful diagnostics to clarify the reasons for infertility is the key before you decide to use one of these methods.

1. intrauterine insemination (IUI)

Procedure: In some cases, IUI is prepared with ovulation-inducing drugs.

During the procedure itself, the sperm are inserted directly into the uterus via a catheter. This can be done at home by yourself or with the help of a fertility clinic. The advantage of IUI is that it is relatively easy to perform, as no surgery is required and in some cases no hormones need to be used.

Application to the following causes of infertility: This method can be used to treat milder forms of infertility:

• In men, insufficient sperm quality or sperm quantity is the cause of infertility
• In women, there is a disorder of the cervix that causes infertility.

Different forms:

• Homologous insemination: the partner’s semen is used for IUI.
• Heterologous insemination: the sperm of a sperm donor is used for IUI.

Main risks: IUI is a relatively simple and harmless procedure and the associated risks are low. Infections and light vaginal bleeding may occur due to the insertion of the catheter. In addition, multiple pregnancies may occur if hormonal stimulation of the ovaries has been performed previously.

Probability of success: IUI has a probability of success of 10-15% per cycle, i.e. usually several attempts are necessary to become pregnant.

2. in vitro fertilization (IVF)

Procedure: In vitro fertilization usually takes several weeks. To obtain enough eggs for fertilization, the woman’s egg production is stimulated with hormones at the beginning of the treatment.

After hormone treatment, eggs are removed from the woman’s ovary and mixed in the test tube (= in vitro) with the partner’s sperm (or a sperm donor).

If fertilization is successful, the fertilized eggs (= zygotes) then mature into embryos in an incubator.

Normally, 2 embryos are transferred into the woman’s uterus on the 2nd day after fertilization (4-cell stage) or on the 5th day after fertilization (blastocyst stage). Surplus fertilized eggs or embryos can be frozen in liquid nitrogen for later use (cryopreservation).

Use for the following causes of infertility: IVF is typically used when there is a slight limitation in the man’s sperm quality or when the woman has problems with ovulation or fertilization.

Main risks: According to the German IVF registry, about 99% of IVF treatments are complication-free, but there are still risks: vaginal bleeding (63% of cases) or bleeding in the abdomen (14%) can occur relatively frequently during egg retrieval

Hormonal stimulation of the development of multiple eggs can cause ovarian hyperstimulation syndrome, which causes the ovaries to swell and hurt. In severe cases, this can become life-threatening.

If more than one embryo is implanted after IVF, you should expect multiple pregnancies. Multiple pregnancies are generally associated with a higher risk of premature birth and miscarriage.

Probability of success: The probability of success in an IVF cycle to give birth to a healthy child is 25-30%. However, as with all methods of artificial insemination, it depends on various factors such as age, number of previous unsuccessful treatments, ovarian reserve, receptivity of the endometrium, etc.

3. intracytoplasmic sperm injection (ICSI)

Procedure: ICSI is a modified procedure of IVF. The preparation of the woman for ICSI is the same as for IVF (i.e. hormone treatment and removal of the egg from the ovary).

However, ICSI differs from IVF in the way fertilization of the eggs retrieved from the ovary takes place: A single sperm is injected directly into each egg under a microscope using a special micropipette. This is also the advantage of this method compared to IVF, namely that on the one hand the best quality sperm can be selected and on the other hand a failure of fertilization can be almost excluded.

Maturation and transfer of embryos are again performed as in the IVF method.

Used for the following causes of infertility: ICSI is often used when previous IVF cycles have been unsuccessful or the man has poor sperm quality, for example, his ejaculate has too few sperm cells or he has an obstruction of the spermatic ducts.

Different forms / complementary treatments:

• TESE and MESA: Testicular sperm extraction (TESE) and microsurgical epididymal sperm aspiration (MESA) are methods of obtaining fertilizable sperm even when there is no sperm in the man’s seminal fluid. Sperm is collected directly from the testicle (TESE) or epididymis (MESA) in a surgical procedure. Fertilization of the partner’s eggs then takes place with the help of ICSI
• Intracytoplasmic injection of morphologically selected sperm (IMSI) is a further development of ICSI specifically for couples after previous failed ICSI cycles. Sperm are analyzed at 6000 times magnification (400 times for “normal” ICSI) and selected for injection into the oocyte.

Main risks: Hormonal stimulation of multiple egg development can cause ovarian hyperstimulation syndrome, which causes the ovaries to swell and hurt. In severe cases, this can become life-threatening.

As with IVF, there is a risk for injury and infection during egg retrieval.

If a surgical procedure is necessary for sperm collection from the male (TESE/MESA), it is associated with a certain risk of complications.

If more than one embryo is implanted after ICSI, you should expect multiple pregnancies. Multiple pregnancies are generally associated with a higher risk of premature birth and miscarriage.

Probability of success:In about 25% of cases, pregnancy can be induced with the help of ICSI.

4. intratubal gamete transfer (“Gamete intrafallopian transfer” – GIFT)

Procedure: This is a hybrid of IUI and IVF. The doctor removes eggs from the woman via laparoscopy under general anesthesia. He then injects these together with prepared sperm cells from the partner either through the abdominal wall or with a special catheter through the cervix into one or both fallopian tubes. Fertilization thus takes place in the woman’s body and the fertilized egg should naturally migrate to the uterus and implant there.

Application in the following causes of infertility: GIFT is used in the following cases:

• In case of long-standing female infertility / unexplained causes of female infertility.
• Certain forms of endometriosis, when scattered cells of the uterine lining hinder the collection of the egg after ovulation
• Male fertility disorders

Main risks: Female laparoscopy under general anesthesia, like all surgical procedures, carries a certain risk of complications.

There is also an increased risk of implantation of the fertilized egg outside the uterus, e.g. as an ectopic pregnancy (10-20%) or abdominal pregnancy.

These two risks contribute to the fact that this method is now hardly ever used.

Probability of success: The probability of success of GIFT is about 20% births.

Sperm and egg donation as additional methods

1. sperm donation

Procedure: Donor sperm can be used in the context of intrauterine insemination (= heterologous insemination) and in the context of IVF/ICSI treatment.

The sperm of the sperm donor is obtained in a frozen state from a sperm bank and thawed and specially prepared before use.

Application in the following causes of infertility: There are basically two groups of causes that speak for the treatment with donor sperm:

• The male partner is infertile, or has very limited fertility and fertilization with the partner’s sperm in the course of artificial insemination has not been successful.
• There are genetic reasons not to use the partner’s sperm (e.g. hereditary diseases)

Probability of success: Only men with optimal sperm quality can be considered as sperm donors. The probability of success of artificial insemination with donor sperm thus depends primarily on the fertility of the woman, i.e. in particular on the age and possible fertility limitations of the woman.

The probabilities of success to a healthy birth are identical to the methods listed above accordingly – after IUI with donor sperm the probability of success is about 10-15%, when used with IVF it is about 25%-30% and with ICSI it is about 25%.

Most important risks: potential sperm donors are screened for genetic diseases and excluded from donation if any are present; however, not all genetic diseases can be excluded and physical or psychological disabilities of the child may result from random mutations, as in any normal pregnancy.

The risks for the mother depend on the method used.

Legal framework: Sperm donation is allowed in all European countries, but there are differences regarding donor anonymity depending on the country.

In Switzerland, Germany and Austria, donor anonymity is now excluded by law; here, the donor child can request information about the identity of the biological father at the age of 14 (Austria) or 16 (Germany) or 18 (Switzerland).

In other European countries, the anonymity of the sperm donor is guaranteed by law, for example in Denmark, Spain, the Czech Republic and Greece. In these countries, only anonymized medical information about the donor can be shared with the donor child or legal representatives if necessary.

2. egg donation

Procedure: In egg donation, a donor (genetic mother) donates her egg, which is fertilized with her partner’s sperm and carried to term by the recipient (non-genetic or gestational mother).

In this case, the donor’s ovaries are stimulated with medication in order to later retrieve several matured eggs from her. The recipient of the donation must also receive hormonal treatment to prepare her to receive the fertilized eggs.

These eggs are then fertilized by IVF or ICSI and implanted into the recipient.

Application in the following causes of infertility: Egg donation is used when the recipient’s ovaries are no longer capable of fertilizing eggs due to her advanced age or due to a disease.

Probability of success: The probability of success of egg donation in terms of birth is up to 40% per transfer and there are no major differences between women of different age groups. This is because the donated eggs come from young and healthy donors.

Main risks: In egg donation, the risk of hypertensive pregnancy disorder (preeclampsia) is increased 6-7-fold and occurs in approximately 23% of pregnancies. Pregnancies following single-cell donation should therefore be closely monitored medically.

Legal framework: Currently, egg donation is prohibited in Switzerland, as well as in Germany. However, egg donation could soon become legal in Switzerland; in March 2022, the National Council approved a motion to that effect, and in September 2022, the Council of States also approved it. This mandates the Federal Council to create a legal basis for egg donation. In Austria, egg donation has been permitted since 2015, and the donor child can request information about the identity of the genetic mother from the age of 14.

In some other European countries egg donation is allowed, such as Spain, Czech Republic, Ukraine and Greece. Donors in these countries are anonymous without exception.

Conclusion

Nowadays, couples with an unfulfilled desire to have children have a variety of different methods at their disposal to fulfill their desire to have children.

However, before deciding on a particular method of artificial insemination, a detailed diagnosis of the causes of infertility in both the woman and the man should be carried out, and the likelihood of success and the risks of different treatment methods should be discussed and weighed up in detail with the attending physician.

In addition, it may make sense to opt for infertility treatment abroad due to differing legal frameworks and, of course, differing cost levels (not discussed here).

Overall, it should always be noted that artificial insemination is not a guarantee of successful pregnancy. The current live birth rate across all methods and age groups of women is 15-20% and falls as women age. After a certain age limit of the woman, de facto only egg donation can be considered to fulfill an unfulfilled desire for a child.

Last update: October 25, 2022