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Donor insemination

INTRODUCTION
Many couples experiencing male factor infertility may choose to undergo donor insemination (DI) in order to achieve pregnancy. During DI, a physician or nurse places sperm from a male other than the female’s partner into the female’s reproductive tract near the time of ovulation. In recent years, DI has become one of the most effective methods for couples with severe male factor infertility to experience pregnancy and childbirth.

WHEN IS DONOR INSEMINATION NEEDED?

Donor insemination may be indicated if there are significantly abnormal semen characteristics and if the female appears to be fertile after a series of tests. Causes for male infertility may include irreversible azoospermia, a previous vasectomy, previous radiation or chemotherapy treatment, or another irreversible male fertility factor.

Additional conditions that may require DI for pregnancy are when the husband or wife or both are carriers of a known hereditary or genetic disorder, such as Tay-Sachs disease, Huntington’s disease, hemophilia, or abnormalities involving the chromosomes. DI may also be used if the female is Rh sensitized and the male is Rh positive. Additionally, single women who desire pregnancy may request donor insemination.

The Evaluation

In order to decide whether to undergo donor insemination, couples need to know the causes(s) of infertility and their chances of pregnancy without DI. The physician will take a detailed medical history from both partners. The male will need a complete examination, including a semen analysis.

The female examination requires a pelvic exam and may include tests for sexually transmitted diseases (STDs) and other diseases. An ovulation detection kit. Basal body temperature (BBT) chart, and in some cases, a cervical mucus examination may be needed to determine the woman’s time of ovulation. In addition, the physician may recommend a hysterosalpingogram, hysteroscopy, or laparoscopy to check for obstruction of the fallopian tubes and to further examine the pelvic organs. An endometrial biopsy may be recommended to determine whether or not adequate hormone production is taking place.

THE INSEMINATION PROCEDURE

Inseminations are scheduled to occur close to the time of ovulation. The time of ovulation is often estimated with the use of ovulation detection kits and/or BBT charts. Inseminations are usually performed once or twice each month depending on the regularity of the woman’s menstrual cycle. The procedure is relatively simple and only takes a few minutes to perform. The woman lies on an examining table and the physician inserts a speculum into her vagina to visualize her cervix. For intracervical insemination (ICI), the physician injects the semen sample into the cervical opening through a plastic syringe (Figure 1). A plastic-coated sponge or cap may be placed into the vagina before the speculum is removed. This keeps the sperm near the cervix and can be taken out four to six hours after the insemination.

Another method, intrauterine insemination (1UI), involves inserting specially prepared (“washed”) sperm directly into the uterine cavity. This method may be used for several reasons, including poor sperm/cervical mucus interaction. 1UI allows the sperm to bypass the cervix so that an increased number can reach the uterine cavity and subsequently the fallopian tubes, where fertilization usually occurs. If the woman has irregular ovulation. the physician may prescribe drugs to induce ovulation. 1UI may be performed in conjunction with these medications to increase the chances of successful fertilization.

Sperm Washing

When 1UI is used, it is necessary to separate the sperm from the seminal plasma. This removes prostaglandins and other substances that could cause adverse reactions or severe uterine contractions. In order to separate the sperm, a laboratory technician will perform a sperm washing procedure. This involves diluting the semen with a sterile fluid and then separating the sperm from the liquid component. The sperm are then returned to a small amount of sterile fluid which is used for the insemination.

Sperm washing attempts to remove chemicals and bacteria that can cause infections or adverse reactions when placed beyond the cervix. Additionally, the washing procedure may increase the ability of sperm to fertilize the egg.

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Figure 1 : Two types of Insemiantion

DONOR SEMEN

The Use of Frozen Semen

Until the emergence of the human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), fresh semen was often used for donor insemination. However, it is now essential that all sperm be frozen and stored for adequate screening because, on the average, it may take from three to five months for HIV to show up on a donor’s blood test. The American Society for Reproductive Medicine (ASRM) recommends that all sperm be frozen for at least six months prior to insemination. The donor is screened for HIV infection at the time of semen donation. The donor is then tested again six months later so that infection undiagnosed at the first screening can be found on the second test. While this does not completely eliminate the risk of HIV infection from DI it does make the risk very small. If one HIV test is negative, the chance of getting an infection is approximately one in 40,000 to one in 150,000. With two tests, it is much less. Recipients of donor semen may choose to be screened for HIV infection as well.

Screening Anonymous Donors

In most cases, anonymous donors provide semen to sperm banks for DI. Patients should make sure that the sperm bank follows screening standards and procedures recommended by the ASRM. Sperm banks should have a thorough medical history of the donor and his family. Donors should be less than 40 years old and preferably have established fertility. Furthermore, they should be required to undergo testing or genetic screening for common diseases, Rh factor, hepatitis B and C. HIV. and other STDs. It is also recommended that less than 10 pregnancies per donor be produced to decrease the chance of offspring intermarriage.

If donor sperm recipients wish to match certain characteristics of their male partner with the donor, sperm banks can often provide information regarding physical traits. Some also provide detailed information on personal habits, education, hobbies, talents, etc. However, there is no guarantee that these traits will be passed on to the offspring. In the case of a woman with no male partner, her characteristics are often matched to the donor’s traits.

In order to prevent future medical and legal problems, it is important to make sure that the sperm bank keeps a permanent confidential record of the donor’s health and genetic screening information, and that the identity and confidentiality of an anonymous sperm donor and the recipient(s) are maintained.

Known Donors

Sometimes couples wish to use a known donor or a relative of the husband so that the baby will be related to both parents. However, there are many issues involved in using a known donor. Over time, the relationship with the donor as well as the donor’s psychological make-up may change. This could create social and legal problems. Furthermore, if the insemination is kept secret, couples may become dependent upon the discretion of the donor. Even when using a known donor, it is still very important to follow the ASRM’s guidelines and to have semen frozen and both the donor and the recipient initially checked for sexually transmitted diseases and the donor checked again six months later. In many states, unless the insemination is done under the supervision of a physician, there may be a question of legal paternity. Consulting an attorney prior to using a known donor may be helpful.

Success Rates

The success rates of donor insemination depend upon several factors. First of all the female’s age is important. Women over 35 have a significantly decreased chance of a successful pregnancy. The predictability of ovulation is another factor. The more regular the woman’s menstrual cycle, the greater the chance of pregnancy. The presence of endometriosis or a history of pelvic infection or tubal disease also decreases the success rate. Success is more likely if the female partner has had a previous pregnancy. Generally, when the inseminations are performed monthly, the overall chance of pregnancy using frozen sperm is about eight to 15 percent each cycle. It is also important that both partners understand that there is approximately a two to four percent chance of birth defects in all children born, including donor insemination babies. The risk of birth defects in children conceived through donor insemination is no higher or lower than the natural abnormality rate.

Other Options

Recent advances in assisted reproductive technologies, such as in vitro fertilization (IVF), have allowed couples with male factor infertility, whose only previous option was donor insemination, to pursue fertility using the husband’s own sperm. With a procedure called sperm aspiration, the physician may be able to retrieve sperm from the male’s testes or the tubes leading from the testes. Even if only a small number of sperm are retrieved, techniques such as intracytoplasmic sperm injection (ICSl) can be used to inject the sperm directly into the egg to facilitate fertilization.

PSYCHOLOGICAL ISSUES

There are many psychological issues surrounding donor insemination. It is important for both partners to completely accept the procedure as an alternative means of having a family. Couples should examine their desire to start a family, the treatability of the male partner’s infertility, the female’s age, and financial factors.

Men may feel a loss of self-esteem and fear losing their wife or partner because of infertility, and women may feel guilt or anger directed toward the male for having a fertility disorder. These and other psychological issues should be resolved before undergoing donor insemination. Most experts recommend that couples seek counseling before the procedure. During counseling, both partners should face their feelings concerning infertility, donor insemination, and any reservations that either partner may have. Couples may find it difficult to talk about these feelings because they seem so personal. However, it is important that couples find ways to communicate their feelings and work through the grief. Physicians can usually provide the name of a support group or counselor specializing in infertility.

The Question of Secrecy

Historically, parents have kept DI a secret from the child and from friends and relatives. Unlike adoption, DI is not obvious to those who know the infertile couple. However, if knowledge of the procedure is concealed, there is always a risk that the truth will eventually be disclosed, causing the child to feel betrayed. Some physicians and psychologists believe that children should be told from the time they are three to six years old that they were conceived by donor insemination. However many physicians maintain that there is no reason for the child to know about the procedure. Available information, although scarce, does not indicate any consistent psychological problems in DI children.

LEGAL ISSUES

There are a number of legal issues concerning donor insemination. It is essential that both partners consent in writing to the procedure. The consent form may state that the recipients will never know who the donor is, nor will the donor know the recipients. With this consent, the baby is the legitimate offspring of the recipient and her male partner, not the donor. If the laws of the state are not known by the physician or the recipients, it may be a good idea to consult an attorney to learn the laws concerning donor insemination in the couple’s home state. If a known donor is used, all parties involved should seek legal counseling and agree upon the donor’s relationship, if any, with the child.

SUMMARY

Approximately 40 percent of infertility cases result from disorders in the male and 40 percent from disorders in the female. The remaining 10 percent are caused by a combination of male and female factors or are unexplained. When male factor infertility cannot be treated, or in a variety of other circumstances, donor insemination is an important option that allows many couples to experience pregnancy. child birth, and the joy of raising children.