Artificial Insemination

ARTIFICIAL INSEMINATION, inseminatio artificialis (a more precise and correct name than artificial fertilization), is the introduction of sperm by artificial means into the genital organs of a female individual (with the help of appropriate instruments). The first mentions of artificial insemination are found as early as Eustachius (Bart. Eustachio) in the 16th century, but it was performed practically much later. The first successful experiments with the artificial introduction of semen into animals (dogs) were performed by the Italian abbot Spallanzani (Spallanzani, 1780); some indicate that as early as 1680, artificial insemination was successfully applied to fish by Swammerdam and Jacobi (1700). In women, artificial insemination was first performed in 1799 by Hunter. Observations and experiments continued in the 19th century, but the scientific development of the issue began only in the last years of the 19th century. Among a number of very interesting works, one should note the experiments of Millais, Heape (1897), and especially Ivanov. The capital and valuable works of Ivanov, which have acquired worldwide fame, laid the actual foundation for this method, brought great benefit in practical terms in animal husbandry, and, moreover, undoubtedly contributed to a greater justification and wider application of artificial insemination in women as well. Ivanov was much engaged in questions of hybridization and the resolution of a number of problems related to fertilization and conception in general. These experiments were subsequently verified by many authors, including Ilyin (1917). The first scientific justification for artificial insemination in women was laid by Sims (Marion Sims, 1866), to whom, in general, belongs great credit for the scientific study of issues related to infertility. Among a number of subsequent works (mainly by French authors), the report of Roubaud to the Academy of Sciences (1872) deserves special mention, in which the question of artificial insemination was set out in detail, and the indications, methodology, and physiological side were analyzed. In recent years, artificial insemination in humans has been studied in detail by Shorokhova and Shorokhov; along with the theoretical study of artificial insemination, Shorokhova devoted much attention to the development of the methodology for obtaining and introducing sperm and the clinical side of the issue. Artificial insemination is currently finding wide application in animal husbandry, in horse breeding farms both in the USSR and in the West, and especially in America. Numerous experiments by Ivanov on large and small animals (cattle, horses, zebras, rams, rats, mice) have shown that with the help of artificial insemination, it is possible in some cases to obtain up to 100% positive results. Correctly performed artificial insemination does not affect the health of the female; the ensuing pregnancy and birth proceed normally. The offspring resulting from artificially inseminated females do not differ in any way from those born from natural fertilization; no predominance of any sex is noted. The observations conducted allowed Ivanov to come to the conclusion that sexual excitement of the female is not mandatory for conception even under natural conditions; when conducting cases of fertilization with spermatozoa in an artificial medium, he established a very essential position that the secretion of the accessory sex glands is not necessarily required for fertilization. The noted facts were pointed out in their time by individual authors in relation to some other animal species (dogs). Thus, Millais, from his 19 experiments on dogs, observed the onset of pregnancy in 15 cases; the pregnancy also proceeded normally, and the birth act occurred without any deviations. The born puppies were fully developed and of high quality. Favorable data were also reported by Heape in experiments with horses. Heape cites successful cases of artificial insemination with malformations of the penis in the stallion and in previously infertile mares. The significance of artificial insemination in mammals and in the economy is considered by many authors not only as a measure to combat the infertility quite often observed in animals, but also from an economic point of view. Thus, along with the noted significant increase in the overall percentage of conceptions with artificial insemination, savings in monetary funds are also noted in the breeding of cattle and horses. Artificial insemination is, of course, of particular importance in cases where the sire is purebred, mating with him is expensive, and meanwhile, the semen obtained from a single sexual intercourse (up to 300 cm³) can be used to inseminate several (more than ten) mares. Artificial insemination of women is currently, in the opinion of the majority of gynecologists, scientifically fully justified and is a fully permissible aid in the therapy of infertile marriages under appropriate, strictly verified indications. The number of published cases is not large, and a fairly large part of them belongs to Russian authors. Shorokhova in 1923 could collect only 88 cases without the observations of Gerard, Chichulin (1924) 139 cases, and Krivsky (1925) 168 cases with 41% positive results. The relatively rare use of artificial insemination can be easily explained by a whole range of reasons, among which, nevertheless, one must place considerations of a scientific nature and, in general, the relative rarity of such cases in which there would be a combination of conditions necessary for performing artificial insemination. Among other reasons that hindered the use of artificial insemination, religious motives played a large role in the past (in this regard, a special "manifesto" issued at one time by the Pope in Rome regarding the inadmissibility and immorality of artificial insemination is very characteristic), and public opinion also had significance: the question of the admissibility and ethics of artificial insemination was discussed even outside the medical periodical press, and it was subjected to sharp condemnation. The legal side of the issue could also play an influence in this regard. Thus, not a few doubts were raised about the future fate of the child, his rights, "legitimacy," as well as the duties of the parents themselves in relation to the child obtained by artificial introduction of semen (without sexual intercourse). These questions were posed especially sharply in those cases where, due to the unsuitability of the husband's sperm for artificial insemination, it was necessary to use the semen of an outside man. Undoubtedly, the small number of existing cases of artificial insemination in women must also be explained by the fact that a certain part of the authors treated this method negatively, considered it unscientific, and, moreover, by the fact that apparently many unsuccessful cases were not published. In the relatively limited application of artificial insemination, a certain role may also be played by the poor familiarity of doctors with this method (Krivsky), as well as either the complete absence of its description in manuals or a somewhat tendentious coverage (e.g., by Gimmelfarb). Indications for the use of artificial insemination are usually the presence of an infertile marriage for 2-3 years. Indications can be both on the part of the wife and the husband. Indications on the part of the woman are, in general terms, all those cases in which, for any reason, there are obstacles or a lack of the necessary conditions for the movement of spermatozoa (e.g., stenoses and narrowing of the cervical canal, changes in the environment and reaction of the vagina), or cases in which the sperm flows out shortly or immediately after the sexual act (e.g., low perineum, flat posterior fornix, short vagina). Among the indications, flexions of the uterus are also put forward, less often vaginismus and so-called "essential" infertility. Dyspareunia, considered by some as an indication, is quite rightly disputed by a number of authors (e.g.

Krivsky, Chichulin), since both the observations of Ivanov and cases of frequent pregnancy in so-called natura frigida show that orgasm is not necessary for conception. Indications on the part of the husband can be divided into 3 groups: 1) cases where, in the presence of a sufficient quantity of spermatozoa of appropriate quality, there is impotentia coeundi (complete or partial inability to have sexual intercourse, ejaculatio praecox); 2) cases of malformations of the penis (in the presence of which the semen cannot enter the vagina—hypo-epispadias) and finally 3) cases where, with full ability to have sexual intercourse, there are deviations in the semen itself (a decrease in the total number of spermatozoa, reduced ability to move). The most controversial indications must undoubtedly be recognized as cases with various kinds of deformations in the structure of the spermatozoon, since in such cases it should already be a matter of using the semen of an outside man. In cases of Artificial Insemination with the sperm of an outside man (not the husband), a whole series of complex questions of a domestic, social, and legal nature arises, which still require their resolution. The basic prerequisites for the performance of Artificial Insemination should be a comprehensive clinical examination of the spouses, the absence of any inflammatory diseases of the female genital sphere, patency of the tubes, and the presence in the man's semen of a sufficient number of motile and normally developed spermatozoa. The latter condition is particularly demonstratively confirmed by the latest detailed studies by Shorokhova. Thus, when examining the sperm of 111 men (in cases of infertile marriages), she noted complete azoospermia in 19.6%, a decrease in quantity and weakening of the motility of spermatozoa in 62.9%, and normal sperm in only 18%. Along with these necessary conditions, contraindications must be equally taken into account. Among them, everyone points to the advanced age of the spouses, various kinds of constitutional anomalies and general diseases (tbc, syphilis, diabetes), sharply pronounced psychopathies, drug addiction, alcoholism. Of course, inflammatory diseases of the genital sphere, certain degrees of vaginal purity, malformations, neoplasms, and the presence of tubal obstruction should be classified as contraindications. A cautious approach is also necessary for uterus infantilis, and for disorders of the ovarian-menstrual cycle (especially with amenorrhea). A narrow pelvis (severe degrees of constriction), which some classify as a contraindication, can hardly be a real contraindication at the present time in the absence of other anomalies. In men, contraindications are changes in the spermatozoon, pathological impurities in the sperm, and unfavorable data from its bacterioscopic examination. Technique of performing Artificial Insemination and methods of obtaining sperm. The technique of performing Artificial Insemination is not complicated, but requires a number of precautions; its performance should take place only in a hospital setting. For some time before its application and before obtaining the sperm, an appropriate lifestyle, proper nutrition, abstinence from alcohol, moderate sexual life, and in some cases its complete prohibition are necessary. Sperm is obtained either by coitus condomatus, coitus interruptus, or by mechanical stimulation (obtaining sperm by direct extraction with a syringe from the vagina is irrational and is not used by anyone). The most common method is obtaining sperm by coitus condomatus. Individual authors, and especially Shorokhova, prefer the other two methods and believe that sperm obtained by coitus condomatus is not guaranteed against the possible penetration of infection (even in cases of sterilization of the condom), since it is put on with non-sterile hands and not on sterile skin (Shorokhova). After sexual intercourse, the condom is tied with a clean thread, placed in a sterile test tube with a stopper, which is lowered into a thermos containing water at 40-43°. After this, the sperm in the thermos is immediately delivered to the institution where the Artificial Insemination will be performed. Shorokhova, based on the experiments of Ivanov, Shorokhov, and others, believes that a thermos is not needed, since the fear of possible cooling of the sperm is unfounded—healthy spermatozoa retain their motility for quite a long time (Shorokhov showed that spermatozoa resumed motility after heating the sperm in a thermostat after an 8-hour stay at normal temperature). The method of obtaining sperm by puncture of the epididymis (in case of obliteration of the seminal ducts), recommended by some, has not gained popularity. Methods of introducing sperm. Semen can be introduced into the vagina or directly into the uterus. Vaginal introduction, with rare exceptions, has been completely abandoned. After preliminary preparation of the intestines and emptying of the bladder, the woman is placed in the position usual for performing vaginal operations. After disinfection of the external genitalia, the cervix is exposed with specula (pre-boiled in a sterilizer together with other necessary instruments), the vaginal part is wiped with a dry swab or washed with cotton balls soaked in physiological NaCl solution (or moistened in a 1% solution of sodium bicarbonate—Shorokhova); grasping the cervix with bullet forceps is not mandatory. Then, a few drops of sperm are drawn from the condom into a Braun syringe (or into a Record syringe with a special, slightly curved cannula attached to it), and the syringe is carefully inserted into the cervical canal past the internal os of the uterus. (In case of impossibility of passing the tip, dilation is performed beforehand with the first numbers of Hegar dilators.) After this, 1-3 drops of semen are released into the uterine cavity without sharp pressure (if there is little of it, it can be diluted with warm physiological NaCl solution or Locke's solution). When inserting and withdrawing the tip through the cervical canal, extreme caution must be exercised to avoid injuring the mucosa. After the introduction of the semen, the vagina can be loosely tamponed (some suggest the introduction of a tampon moistened with the remaining sperm) and the woman placed in a position with a raised pelvis. Subsequently, staying in bed for 1-2 days is desirable (others consider a quiet position for 1/2-1 hour sufficient). In the coming days, a prohibition on physical labor and complete abstinence from sexual life is necessary at least until the time of the next menstruation. Regarding the timing of sperm introduction depending on menstruation, there is no unanimous opinion. The majority believes that Artificial Insemination should be performed after menstruation and that the best time is the 8th-10th day after its end. Terebinskaya-Popova considers the time immediately after menstruation to be the most favorable; Shorokhova used Artificial Insemination both before and after menstruation (in most cases before) and pointed out that there is still insufficient material to judge whether there is a dependence and what it is between the time of sperm introduction and conception (in relation to menstruation). Results and fate of children. As indicated in the table, the percentage of positive cases reaches 43. Especially interesting is the case of Cary, in which, after successfully applied Artificial Insemination, infertility occurred again. After a long time, Artificial Insemination was performed again with a positive result. In a number of described cases, pregnancy and childbirth proceeded normally. In some cases, abortions were observed (which could not depend on the method) and in one, the onset of an ectopic pregnancy was noted. Once, twins were observed. Artificial Insemination can be considered harmless to a woman's health; this even allowed individual authors (Shorokhova) to recommend it not only for the therapy of infertility, but also for the treatment of dysmenorrhea. Children were born completely healthy and did not show any deviations in their further development.

S. Seditsky. OSIPOV Viktor Petrovich (born in 1871), a well-known contemporary psychiatrist, professor of the Military Medical Academy in the department of psychiatry, director of the State Reflexological Brain Institute named after Bekhterev. He graduated from the Military Medical Academy in 1895 and was retained at the department of psychiatry. In 1898, he defended his dissertation on the topic of contractions of the stomach, intestines, and bladder during epileptic seizures (St. Petersburg). In 1899, he was sent abroad, where he worked under the guidance of prominent scientists (Kraepelin, Munk, Nissl, Oppenheim, Mechnikov). In 1901, he received the title of privat-docent. In 1906, he was elected to the chair of psychiatry in Kazan, where he was the dean of the medical faculty and one of the founders of the People's University. In 1914, he was elected to the chair of the Military Medical Academy; since 1939, he has been the director of the Brain Institute. He has about 130 printed works; in his works, he is a representative of the pathophysiological direction; neces-

It is necessary to note the work of O. on Kahlbaum's catatonia, work on the prevention of mental diseases, and many others. O. is the author of a major textbook on mental diseases (Berlin-Leningrad, 1923-26) and editor-in-chief of the "Small Encyclopedia of Practical Medicine" (volumes I-VI, Leningrad, 1927-30). He serves as chairman of a number of scientific societies, is one of the founders of the Pedological Society and its first chairman; he was chairman of the doctors' trade union, a member of the board of the SNR, a member of the Leningrad Soviet of the XII convocation, a member of the State Academic Council and the Scientific-Medical Council, and a member of VARNITSO. He is a member of the editorial board of the "Vrach-ebnaya Gazeta" (Medical Gazette) and a number of other periodicals.