Artificial insemination

[2] Artificial insemination is a relatively simple medical procedure by which semen obtained by masturbation is deposited by means of a syringe in or near the cervix of the woman's uterus. Artificial insemination is of two basic types: homologous insemination, when the semen is obtained from the husband (AIH); and heterologous insemination, when the semen is obtained from a donor (AID). AIH is used occasionally when for physical or psychological reasons insemination through intercourse is problematic, or in the case of oligospermia (deficient sperm count) when sperm from several ejaculates are pooled for use in a single insemination. Since AIH presents few legal, social, or ethical problems, this paper will focus primarily on AID.

JOHN 0. HAMAN, M.D., San Francisco E ACH year in this country 50,000 couples marry who cannot have children and there are always 2,000,000 couples who are involuntarily childless. Ten per cent of involuntary childlessness is because the male is either azoospermic or his semen so severely deficient that treatment is hopeless. There are always among us, therefore, some 200,000 husbands who will never be able to produce offspring. This figure will grow as marriages increase, and it is for this large group that artificial insemination holds promise.
These couples have few alternatives: First: They can attempt to adjust themselves to the realization that theirs will be a childless union.
Second: They can adopt children. Third: They can divorce and remarry. Fourth: The wife can have extra-marital coitus, with or without her husband's consent.
Fifth: They can have artificial insemination performed.
Historically, it is generally believed that artificial insemination was first practiced in 1322-upon animals. (A cunning Arab sheik who w'as jealous of a rival stole into an enemy camp in the dead of night and artificially inseminated all the mares with semen of an inferior stallion.) But now, an overlooked Talmudic document has been brought to light. It antedates the time of the Arab tale by approximately 1,100 years. Furthermore, this document discusses in academic manner the artificial insemination of humans, although no mention is made of its intentional application.
During the 17th and 18th centuries, Swammerdam, Jacobi, Spallazani and others experimented with artificial insemination in different animals. Later, John Hunter and J. Marion Sims inseminated humans with some success, but soon gave up the practice.
Ivanoff introduced artificial insemination in animal husbandry into Russia in 1899 and since that time it has been used extensively to improve the livestock of the state controlled farms. In this manner the services of valuable sires have been spread over large numbers of cows, ewes, and mares. In 1936 alone, more than six million cattle and sheep were artificially inseminated, as many as '15,000 ewes being inseminated by a single ram and over 10,000 cows by one bull. The excellent results obtained in animal artificial insemination revived interest in the application to humans. From 1902From to 1938, only 24 articles on the subject appeared in the American literature, but since then interest has steadily increased.
The physician treating an infertile couple is faced Read before the Section on Obstetrics and Gynecology at the 76th Annual Session of the California Medical Association in Los Angeles, April 30-May 3, 1947. with many problems. Probably the greatest is posed when he finds the wife to be normal and the husband sterile. He must then inform the couple of their status, and explain the alternatives open to them. If they decide that artificial insemination is the solution to their problem, his duty and responsibility is greatly increased. The physician must carefully explain the entire procedure to both husband and wife and must point out both the advantages and disadvantages of this method of reproduction. He must be certain that both husband and wife are equally serious and sincere in their request for artificial insemination and that they grasp the psychological and emotional dangers which they face, and that they clearly understand that these problems may recur throughout the remainder of their married life. If either partner shows only half-hearted interest, the subject should be dropped immediately. An important prerequisite is a probationary period during which the physician will see both the husband and wife and familiarize himself with the mental and psychological make-up of the couple. This "coolingoff" period gives the couple an opportunity to review the picture dispassionately and permits the husband to reconsider what may have been an act of bravado, pity for a childless wife, or an expression of his own wounded pride. The husband must clearly understand the possible emotional effect that this procedure may have on his future relationship with his wife. He must be aware that present sentiments are not always enduring.
It is the physician's solemn duty to refuse artificial insemination if he is not convinced that his patients are fully capable of the great adjustment necessary. By such refusal he saves himself, the husband, the wife, and above all, the potential child, much unhappiness.
The abnormal conditions present in husband or wife indicating artificial insemination, using either the husband's or a donor's semen, can be divided into three groups: 3. Severe dyspareunia. 4. Impairment of the cervical passage. C. Sterility with no evidence of cause in either partner. Group A presents definite reasons for performing artificial insemination and the percentage of pregnancies is high.
Group C is a composite group with no definite indication, few advocates, the percentage of pregnancies small and the hazards encountered great.
The prerequisites for artificial insemination with a donor's semen are five in number: 1. The couple must desire this method of treatment and understand its legal and psychological consequences.
2. The husband must be irreparably sterile.
3. The wife must produce normal functioning ova in a great majority of cycles. 4. The wife's tubes must be patent and show normal peristalsis.
5. The wife's pelvic organs must be normal. Various procedures have been utilized for depositing the sperm in portions of the female genital tract. The semen has been placed in the vagina, onto the cervix, into the cervical canal, into the uterine cavity, and directly into the tubes. It has been centrifuged before insertion and also mixed with a variety of fluids and then injected. The semen has been obtained by many methods, masturbation, withdrawal, condom, aspiration from the testicles, and even physiologic artificial insemination by injection of semen from a normal individual into the seminal vesicles of a sterile husband, to be followed by coitus soon after.
The common methods of implanting the semen in use today are intracervical or intrauterine. With a donor's semen it is only necessary to place the sperm at or into the cervical os. However, if the husband's semen is used, it is usually placed in the uterine cavity itself, a dangerous procedure.
Intrauterine insemination is used too frequently and often without an understanding of the indications, the principles of technique, or the risks involved. The fact that a defective seminal fluid is most probably not capable of fertilizing an ovum even if it were deposited directly upon it is a factor very often forgotten. Guttmacher's statement, that "giving sperm a three-inch boost on a six-inch journey is valueless," is based on this fact.
It must be kept constatitly in mind that complications may occur. They are not common, and although usually of a minor nature, they are a potential source of serious danger. Several cases of acute salpingitis and pelvic abscesses have been reported. Siegler and Franz have each reported a death following insemination.
These acute pelvi-infections may arise from the use of infected semen or from relighting of a dormant tubal infection, or they may be caused by carrying infection up into the uterus from an infected cervix or vagina. Chemical peritonitis may result from using too much pressure and forcing the semen through the tubes into the peritoneal cavity. The possibility of causing endometriosis, endocervicitis, puncture of the uterus and tubal pregnancy must also be kept in mind.
Careful selection of a suitable donor is paramount.
The donor must remain anonymous to the prospective parents and under no conditions should a member of the family be considered as a donor.
The donor should have the same racial and physical characteristics as the husband and his emotional make-up should approximate that of the husband. He should be 30 to 35 years of age, in perfect health, with no history of familial or inherited diseases, no history of venereal diseases, of superior mentality, and, of course, highly fertile. If possible, the blood group and the Rh factor should be the same as that of the wife.
The timing of the insemination is usually based on the wife's cyclical dates and her basal body temperatures. Insemination is performed, for the first month or two, several times near the midcycle, in an attempt to inseminate at ovulation. After a chart has been compiled for several months, insemination is performed on the day of the drop in temperature and the day of the first rise.
In all cases of the author's series in which the patient became pregnant, insemination was performed either the day before the drop, at the drop, or on the first rise. This substantiates the claim made by many that the basal body temperature is the most reliable of all simple clinical methods known at present to determine ovulation time.
This system worked well where the periods were regular, but where the menstrual cycle was irregular, several attempts were necessary during the month at two to three-day intervals. Here again, however, reliance was placed on the basal body temperature curve to show when ovulation took place.
The results obtained in the author's series correspond closely with the aggregate of those reported by others since 1866 (Tables 1 and 2). In a total of 66 cases, 24 patients became pregnant (36.3 per cent). Thirty-six of the wives were inseminated with a donor's semen, 19 becoming pregnant (52.7 per cent). The husband's semen was used in 30 cases, and in only five, or 16.6 per cent, did pregnancy result.
Of the 66 patients inseminated, 27 had husbands who were azoospermic, nine had husbands with very severe oligoospermia, one a husband who had a hypospadius. Husbands of the remaining 29 were apparently normal. Twenty-three of the 29 patients whose husbands were normal, however, themselves had abnormalities of the cervix.
Inseminations performed on the 66 patients averaged 6.34 per patient (Table 3). The patients were   1936 1937 1938 1938 1939 1940 1941 1941 1941 1941 1943 1944 1944 1944 1944 1944 1944 1945 1946   inated an average of 2.29 cycles and the AID patients an average of 4.77 cycles. There were 13 patients that were inseminated only in one cycle and immediately became pregnant. Also, there were a number of patients, usually those who were being inseminated with the husband's semen, who became discouraged early and stopped inseminations in one to three months (19 out of 24), hardly long enough to give the procedure a fair trial. The successful insemination dates were from day 11 to day 18 (Table 4).
There were eight males born and eight females, and there were two miscarriages. Outcome of the remaining six cases in which pregnancy occurred is unknown because of losing track of the patient.
The length of pregnancy (eliminating the two premature labors) was from 257 to 280 days after conception, the average being 270.5 days. There were no tubal pregnancies in the series. Two of the patients had premature labors, one at 238 days and one at 247 days. The babies survived, although one died later of dysentery. There were two patients who required cesarean section, both because of failure of the cervix to dilate. Both patients had been inseminated with donors' semen. There are ten patients still under treatment, but they are included in the series. It is interesting to note that 42 different donors were used, but 15 accounted for all the AID pregnancies, one accounting for three and two for two pregnancies each. It was also noted that with the semen from many of the donors the sperm invasion and migration was consistently poor, but the sperm of the 15 accounting for all the AID pregnancies was consistently above average in this respect.
The following complications occurred: Three patients, two with the husband's semen and one with that of a donor, developed acute pelvic inflammatory disease requiring hospitalization. They were given penicillin and sulfathiazole and none developed a pelvic abscess. There were also two cases (both AID) of transient endometritis, but the patients recovered uneventfully in a day or two.
Space does not permit a full review of the legal aspects, but the ordinary rules of law governing doctors are applicable to artificial insemination.
Whether artificial inseminations will ever be approved or accepted will depend upon the results obtained and indisputably established by reputable workers in this field.
There are three well defined pitfalls awaiting the physician who practices artificial insemination: First, the allegation of negligence; second, interference with the rights of the parties, giving rise to possible charges of adultery; third, allegation of conspiracy.
Neither California nor any other jurisdiction has any statutory law aimed at artificial insemination. The law has not kept pace with the advances made in medical science and particularly in the development of artificial insemination. The expressions of public policy and the rights of individuals contained in our statutes have no more contemplated the governing of this field than they have the use of the atomic bomb. The courts have considered the question only rarely and in those few instances the views expressed have been so divergent and so far removed from the cause at hand as to lack authoritative weight.
Case law on the subject seems to be limited to the dictum (language not binding upon future decisions) in one Canadian case, Orford vs. Orford. The court denied the woman plaintiff's claim for alimony, but stated that, in the court's opinion, not the intercourse of the parties but the voluntary surrender of the wife to the reproduction faculties of another person without the husband's consent constituted moral turpi-tude and adultery. This opinion, so often quoted, is not only merely dictum but also falls short of establishing an opposing precedent, in that it proceeds from Ecclesiastical Law, not recognized in the United States, and is based on the lack of the husband's consent.
However, in a more recent unreported decision by a court in Cook County (Chicago) Illinois, the opinion was expressed that artificial insemination did not constitute adultery.
To protect the physician against the possibility of a civil suit, written consent to the artificial insemination, signed by both husband and wife, should be obtained. In this consent should be set forth in detail the act to be performed and its possible consequences, both legal and medical. We.
-being husband and wife and cohabitating as such and being over the age of 21 years of age and residing at .,,--,--,,, -,,,, of our own free will and volition do request of Dr.
.,,,,,,-one of the undersigned herein, artificially with the sperm of a white male selected or to be selected by the same Dr.
We understand that more than one attempt at artificial insemination may be required and there is no representation on the part of Dr.... ,,,,,,,, .as to the number of attempts. We fully understand that Dr. does not or did not represent or warrant that a pregnancy or full-term pregnancy will result from such artificial insemination; further, under no circumstances shall we demand that the name of the donor of such sperm be divulged.
That we release the said Dr. of any and all responsibility in the event that the issue that may result from said artificial insemination is abnormal in any respect.
If properly worded it would be as much a safeguard to the doctor as any form of consent customarily used in connection with surgical operations. The consent form used by the author is taken in part from that used by several different authors, with details necessary for protection under California laws.
Lews pertinent to paternity generally contain a provision to the effect that the issue of a wife cohabiting with her husband is presumed to be legitimate. Under California law this presumption (Civil Code, Section 194) is conclusive and indisputable if the husband is not impotent. This opens only two avenues to attack the legitimacy of a child born in wedlock. Although there is no agreed legal definition of the word impotent, it seems to include inability to copulate rather than inability to reproduce.
Therefore the only successful attack on the legitimacy of a child born in wedlock (or within ten months after dissolution of a marriage) must be based on lack of proof of cohabitation or impotency of the husband.
The author feels that the ultimate trend of legislation on artificial insemination will depend primarily on the manner in which this delicate situation is handled by the medical profession. In other words, although there is nothing unlawful at present in artificial insemination as practiced by reputable doctors, the smallest lack of integrity, care or attention to the absolute requirements of such practice might easily bring about unfortunate occurrences which, with attending publicity, might well cause a revulsion of public opinion, resulting in legislation which would ban the practice entirely.

SUMMARY AND CONCLUSIONS
The number qf childless marriages in the United States is constantly increasing. There are always at least 200,000 husbands who will never be able to produce offspring. Artificial insemination offers the possibility of children for the wives of this large group in our country.
There are certain prerequisites that must be strictly adhered to. Both husband and wife must understand the psychological adjustments that are necessary to assure continued marital happiness.
The methods of insemination are briefly reviewed, and the complications, especially from the use of the husband's semen, are enumerated.
Careful selection of the donor and the preservation of his anonymity is paramount.
Results show that insemination with the husband's semen is only successful in a small percentage of cases (16.6 per cent) while insemination with a donor's semen gives far better results, 52.7 pregnancies per cent.
Legal aspects are briefly reviewed, especially those pertaining to California law.
The future trend of legislation on artificial insemination depends primarily on the manner in which the situation is handled by the medical profession. COMPLETE vesical diverticulectomy can be a formidable operation. Fortunately, many diverticula empty with the bladder when the obstruction is removed and operation is not necessary. In other cases, in the relatively minor operation described by Young, the mucous lining may be removed and the stoma closed by an intravesical approach, using a paravesical drain.
More extensive sacs may be attacked by dividing the bladder wall down to the opening, and then mechanically stripping out the lining, leaving the fibrous wall intact. All of these procedures have the merit of avoiding exposure of the deep pelvic structures to infection and of injury to the ureters, the vas deferens, and the rectum, large vessels and nerves. Some diverticula have long harbored infection or stone, and the lining is so adherent and inaccessible as to be extremely difficult to remove. In such cases the tedious and hazardous operation of total diverticulectomy has been done and the mortality is very considerable. This procedure may nevertheless be necessary if the ureter empties into the diverticulum, and its opening cannot be trans-planted by Young's plastic operation; or, if there is a tumor in the diverticulum. Inadequate drainage in such cases may necessitate a perineal drain.
The patient should be well prepared by proper water balance, drainage, urinary antiseptics, protein fortification, and attention to the cardiovascular system. Draining the bladder does not necessarily drain the diverticulum. In preparing infected diverticula with an accessible stoma, the author has inserted into it a panendoscope, and, withdrawing the telescope, passed a catheter into the bladder as an outflow. Both are secured. A constant, rapid drip of a mild antiseptic will clear up a foul diverticulum, which bladder drainage alone will not do.
On any prostatic service there are many pitients handicapped by cardiac or renal insufficiency, obesity, senility or general weakness, some of whom have deep paravesical or subvesical diverticula, difficult of access, in which sufficient dissection, even to adequately strip the lining, is too dangerous. In such cases the procedure applied in the case cited may be lifesaving. The author has not seen it described.