Therapeutic Donor Insemination (TDI) / Donor Insemination (DI)

Introduction

One of the options for treating severe male factor infertility, or for achieving fertility where no male partner is involved, is artificial insemination using donor sperm or, more commonly, donor insemination (“DI”). The acronym “AID” is no longer used since the advent of AIDS, and sometimes the procedure is called “therapeutic donor insemination” or TDI. DI involves placing cryobanked sperm from an anonymous donor in the uterus just before the time of ovulation.

When to Use Donor Insemination:

Therapeutic insemination using donor sperm may be the treatment of choice in the following cases:

1. When the sperm count is very poor and there are no treatment options to improve sperm count and quality
2. When it is not possible to recover sperm capable of fertilizing an egg – even by ICSI
3. When the man is a carrier of an undesirable hereditary condition
4. When ICSI/IVF is not financially possible (the average cost of an IVF/ICSI cycle is about $7000 to $9000)
5. For single women or same sex couples

Where Do Donor Sperm come from?

Donor sperm is obtained from reputable sperm banks that must meet strict standards imposed by Health Canada. Rigorous screening is performed on each donor before collecting and freezing sperm. The screening process includes a thorough family history, complete medical and social history, blood typing, screening for genetic disorder, sexually transmitted diseases, hepatitis B and C, and HIV. Potential donors are not accepted if there are any abnormalities detected in any of the screening tests. Furthermore, each frozen specimen is quarantined after freezing and only released for use if the donor remains free of any infectious illnesses at least 6 months later. Only sperm and banks that meet the Health Canada standards can be used for donor insemination in Canada.

How Do I Choose a Sperm Donor?

The sperm bank will provide a list of donors available. Brief descriptions will be given of the donor – including racial or ethnic background, blood type, certain physical characteristics and/or certain social characteristics that may be important to you. More detailed profiles are normally available from the sperm banks on request, although there is usually a charge for this extra service.

How is Donor Insemination Done?

Before embarking on donor sperm insemination you will be evaluated to rule out any obvious fertility problems. Your menstrual cycles will be monitored with a basal body temperature chart to see if you are ovulating. This will give information about the length of your cycle, and at what time of the month you normally ovulate. As part of your work up some baseline investigations will also be performed. These will include some hormone tests, blood tests to rule out infectious illnesses such as hepatitis B and C, HIV, as well as genital tract cultures. The exact timing of ovulation will be determined by you checking your urine each day leading up to your fertile period using an ovulation predictor kit. Approximately 24–36 hours prior to ovulation (that's when the egg is released) a hormone called luteinizing hormone (LH) appears in your urine. The ovulation predictor kit allows you to monitor your urine for the presence of this hormone. When the test is positive we will know that your egg will be released the following day.

From experience, the most useful ovulation predictor kit is Clearplan.

When the urine test is positive you will need to contact me so that arrangements can be made for the insemination to take place the following day.

Inseminations are performed seven days per week.

If you do not ovulate regularly, or if your cycles are unpredictable, you may be asked to use a fertility enhancing (ovulation induction agent) such as Clomiphene.

The actual insemination process is very like having a Pap smear done. A speculum is inserted into the vagina, and the thawed, washed sperm is injected through the cervix into the uterine cavity using a special thin catheter. Sometimes this might cause a sharp cramp, which usually subsides after a few minutes, although you might also experience some discomfort a few hours later. The actual insemination procedure usually only takes a few minutes. Sometimes difficulty is experienced passing the catheter through the cervix, and the cervix will need to be held steady using an instrument called a tenaculum.

After the insemination you will be asked to lie quietly for 5–10 minutes, after which you will be free to leave the office and resume normal activities. We do however ask that you do not do any major exercise or go into a hot tub or public swimming pool for 24 hours after the insemination.

How Successful is Donor Insemination?

This depends on many factors, the most important of which is your age. For women under the age of 35, with no other fertility-related health problems, the success rate is about 15 – 20 % per treatment cycle or about 60% after 6 months. Success rates decrease as you get older.

If you are not pregnant after 6 treatment cycles, further investigations might be suggested. If no fertility related problems are identified, it might be suggested that you consider increasing the chance of pregnancy by using certain fertility drugs. There are a variety of different fertility enhancing medications which could be discussed with you.

Is Donor Insemination Safe?

Donor insemination is a very safe procedure, especially when no medications are used. Once a pregnancy occurs, it is no different to one that occurs naturally in a woman of the same age. The risk of miscarriage is not increased, remaining at about 15% for women under the age of 35. The risk of congenital abnormalities is also the same as would be expected for anyone conceiving naturally. However, if fertility-enhancing drugs are used there might be other risks such as multiple pregnancy.

What are the Legal Implications?

A child born through donor insemination is considered to be the legal child of the mother and her spouse or partner. The legal obligations of the mother and her spouse to such a child are no different to that of any other couple.

If you and your partner are not legally married, and there is any concern about your obligations to the child, you should consult your lawyer prior to committing to this treatment.

Is Donor Insemination Confidential?

This is a highly confidential process. It is not necessary for you to disclose your participation to anyone. You will not have access to the identity of the donor, nor will the donor have access to your identity.

You might or might not choose to discuss this process with your family, friends, or the children that result. These are some of the many issues that you should discuss with a counsellor before starting treatment.

What Does Counselling Involve?

The Provincial Health Services Plan does not cover the consultation with the Counsellor, for which you will be charged a fee, presently $130 for a 1-hour session.

What Does Donor Insemination cost?

1. Counselling: The counselling session is, at the time of preparing this InfoSheet, $130 per hour. You will be billed by the Counsellor and pay her directly
2. Sperm Samples: Donor sperm samples must be bought from a donor sperm bank that is approved by Health Canada. Although many donor sperm banks list samples as either washed or unwashed (washing is a process that separates the good sperm from the liquid part of the semen and suspends them in a special culture medium), we recommend that after thawing, all sperm samples are washed to remove the cryoprotectant that was used to protect the sperm during freezing (like antifreeze). This is particularly important because we recommend inseminating the sperm directly into the cavity of the uterus, since this increases the chance of conceiving in each treatment cycle, Therefore - we recommend that unwashed specimens are purchased (since they’re cheaper and contain more sperm), and we will do the washing in our lab after thawing the sample, before the insemination. The cost of each donor semen specimen varies from one bank to another, but is generally around $400.00 per unit
3. Courier Fees: These are variable and depend on whether you choose a standard or priority service for shipping the semen from the cryobank to the VFC
4. Storage: Ongoing storage of the frozen donor sperm samples in the VFC cryobank also attracts a fee. There is also a handling fee for processing the paper work and transferring the samples to the VFC Cryotanks (see current price list)
5. Insemination: The cost for each insemination (see our current price list) includes the thaw, post-thaw sperm count and assessment, washing, and the insemination itself
6. Fertility Drugs: These may or may not be required. There are different types of fertility drugs and treatment regimens that might eventually be used, and they vary tremendously in cost
7. Ovulation Predictor Kits: The most reliable kit to use is ClearPlan. Depending on where you buy them, these vary in price between $35 and $50 for a kit that allows you to do 5 tests

Ordering Donor Semen

There are a number of reputable sperm banks in North America. but the three preferred by VFC are ReproMed, which is based in Toronto, Xytex, which is based in Atlanta, and Can-Am Cryo Services in Toronto. Their websites are as follows:

www.xytex.com
www.repromedltd.com
www.canamcryo.com

When visiting the Xytex website, be sure to choose a donor from the Canadian list only.

When you are ready, you will need to coordinate the ordering of your donor semen with the VFC. When you have chosen a donor, please call one of our embryologists to make all the necessary arrangements.

(Before choosing a donor and ordering sperm, you need to know your CMV status. Cytomegalovirus (CMV) is a common virus in the community – which causes a flu like illness. Most adults are immune to it. As part of your assessment, you will be having a blood test to check whether or not you have had CMV in the past. If you have – you will have antibodies against CMV – and cannot get the infection again. If you are negative, it means that you have never had CMV – and that you are still susceptible to it. If you do not have antibodies against CMV – you should preferably choose a donor who is also CMV negative.)

The Cycle Itself

Once everything has been organized, and the sperm samples have been received from the donor bank, you will be ready to go. By this time I will have had a chance to review a basal body temperature chart and would have advised you on what day to start checking your urine using the ovulation predictor kit.

• Please notify VFC when you get your period so we are aware that you will be having an insemination
• When your ovulation predictor kit is positive you contact VFC and we make arrangements for the insemination to be done the following day
• You will be given a sheet of instructions on exactly how to use the ovulation predictor kit, as well as the phone numbers to contact me after hours

What About Future Pregnancies?

Many women who choose donor insemination would like the option to use the same donor for further pregnancies. If this is a consideration, you might wish to purchase extra samples from the donor sperm bank to store in the VFC cryobank. These sperm samples would then be available for you to use whenever you are ready. There is no limit to the number of pregnancies that you can attempt.