Donor Insemination

 Donor Sperm / Donor Insemination (DI)
We welcome you to PREG’s DI program and look forward to working with you. We encourage you to ask questions about your care and both your physician and clinic nurses are good resources.  We realize that you probably have already invested a large amount of time and thought into your decision to consider donor insemination (DI) and understand this has probably been a stressful one.
Use of donor sperm allows patients with no sperm exposure or severely abnormal sperm counts in their partner to have the opportunity to conceive a pregnancy by way of intrauterine insemination or IUI.  Intrauterine insemination (IUI) is the placement of a sperm sample into the uterine cavity to increase the number of sperm that may then get out into the fallopian tubes where the egg is present after ovulation.  Since consent forms for Donor Insemination must be signed by both husband/partner and wife, we request that your husband/partner come with you for this visit.
Indications for Considering DI

A. The male partner has no sperm present (azoospermia), or very low number of sperm present (severe oligospermia), or other significant sperm abnormalities.
B. The male partner is not able to ejaculate any semen specimen.
C. The male partner has prior failure to fertilize after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) or in cases where IVF/ICSI is not a treatment option.
D. The male partner has a significant genetic defect or the couple has previously produced an offspring affected by a condition due to the male partner’s genetics.
E. The male partner has a sexually transmissible infection that cannot be eradicated (HIV, Hepatitis, etc.).
G. Females without male partners.
Your First Appointment
Forward to us any medical records pertaining to your previous infertility care or bring them with you at your initial appointment.  During that visit, your physician will take a family and medical history, perform a physical examination (including a pelvic exam) and obtain laboratory evaluations including several blood screening tests that have been recommended by the Society for Reproductive Endocrinology for all patients undergoing DI.
At PREG, we follow the 2006 Guidelines and Minimum Standards for Gamete (sperm donation and therapeutic donor insemination) published by the American Society for Reproductive Medicine (ASRM) which provides the latest recommendations for evaluation of potential sperm donors, incorporating recent information about optimal screening and testing for sexually transmitted infections (STIs), genetic diseases, and psychological assessments. This current guideline incorporates recent information from the US Centers for Disease Control and Prevention (CDC), US Food and Drug Administration (FDA), and the Society for Assisted Reproductive Technology (SART), and American Association of Tissue Banks (AATB). The FDA has published requirements for the screening and testing of donors of human cells, tissues, and cellular and tissue-based products (HCT/Ps), which are included here. These are the minimum requirements mandated by the federal government.
Evaluation of the Male Partner (if applicable)
The male partner in any couple that requests DI should have completed an appropriate clinical evaluation to include:
1. Review pertinent medical history and medical records and if appropriate, alternative treatments (Testicular biopsy, IVF with ICSI, etc.) should be discussed with the couple.
2. Human immunodeficiency virus (HIV) testing of the male partner is recommended strongly to address potential medical/legal issues that could arise if his partner develops HIV during or after DI.
3. Testing for other sexually transmitted infections (STI’s) similar to that recommended for the female partner is encouraged (i.e. blood tests for syphilis, Hepatitis B surface antigen, Hepatitis B core antibody (IgG and IgM), Hepatitis C antibody, and Human T-cell lymphotropic virus (HTLV) type I and II)

Evaluation of the Female Recipient
A. Routine medical and reproductive history is obtained according to the standards that are applied to women anticipating pregnancy. Abnormalities detected from history or physical examination may require more detailed evaluation and treatment before proceeding with insemination.
B. A complete general physical examination should be performed; including a pelvic examination and pap smear, within one year of treatment (your OBGYN can do this). 
C. Standard preconception screening, testing and counseling:
1. Required tests include:
a. Blood type, Rh factor, and antibody screen.
b. Rubella (German Measles) and Varicella (Chicken pox) titers. (If there is a positive history of chicken pox then would not need to test varicella titer). Vaccination (at local Health Department) should be offered if the individual is not immune to either virus.
c. Neisseria gonorrhea and Chlamydia trachomatis.
d. HIV-1 and -2 testing should be performed to address potential medical/legal complications that could arise if the recipient (patient) becomes HIV positive during or after treatment. In addition, if the female recipient is found to be HIV positive before treatment, she should be referred to an appropriate infectious disease specialist for counseling on issues concerning HIV disease, including reproductive issues such as safe sex practices for preventing HIV transmission and treatment options to reduce the probability of transmission to her child. A positive HIV-1 or -2 test of the female recipient should not be used as an exclusionary criterion for treatment with DI as long as the couple makes an informed decision following counseling and agrees to comply with recommended clinical management for the positive HIV status during pregnancy.
e. Serologic test for syphilis.
f. Hepatitis B surface antigen.
g. Hepatitis B core antibody (IgG and IgM).
h. Hepatitis C antibody.
i. Human T-cell lymphotropic virus (HTLV) type I and II
j. Cytomegalovirus (CMV) antibody (IgG and IgM). (optional) For women who test positive for CMV active infection, attempts to conceive should be postponed until they no longer exhibit active infection, due to the risk of transmitting the infection to their fetus and the serious potential consequences of fetal CMV infection. PREG generally recommends using a CMV negative sperm donor.

Evaluation for possible tubal or peritoneal abnormalities

Patients who fail to conceive after three donor sperm inseminations may be candidates for a hysterosalpingogram (HSG), laparoscopy, or other appropriate tests to detect possible causes for their failure to conceive including fallopian tube blockage or disease.   Pretreatment HSG or laparoscopy may be indicated by the history and/or physical findings.

Psychological Consultation and Consent (optional)

The decision to proceed with donor insemination is complex and patients and their partners may benefit from psychological counseling to aid in this decision. At PREG, we offer psychological counseling by a qualified mental health professional to all couples who desire counseling. Recipients of donor gametes may receive counseling about the potential psychological implications, about their subsequent feelings concerning the medical conditions that necessitated the use of donor gametes, address the impact of successful treatment: feelings during pregnancy, positive and negative aspects of disclosure and nondisclosure with offspring, potential impact of multiple pregnancy, transition to parenthood, parenting at an older age (if applicable), and non-biological parenting issues. The impact of treatment failure should also be addressed: coping with treatment termination, the grieving process, and developing alternatives for the future. In cases involving known donors, related issues, such as the potential impact of the relationship between donor and recipient, should be explored. The recipients should be informed about the screening and testing required of the donor. The couple should be made aware that a donor may be deemed unsuitable for donation and that the practice may refuse to use these gametes for treatment. If the recipient couple elects to use a donor who is deemed unsuitable, then additional counseling must involve risk management and an agreement that the recipient couple understands and assumes the risk. Couples should be informed that the records related to the screening and testing of the donor will be stored. The storage of this information is relevant to the recipients because it relates to other information-sharing decisions they may make.

Directed donation (use of known sperm donors)

Directed (non-anonymous or known) donation is acceptable if all parties agree. Known donors must undergo the same screening and testing as anonymous donors and this must be done through a FDA approved commercial sperm bank (not done at PREG). PREG’s policy regarding directed sperm donors follows ASRM guidelines in that directed-donor specimens should be treated in the same manner as anonymous-donor specimens.  Results of screening or testing that would exclude an anonymous donor also should exclude a directed donor.  All directed-donor specimens will be quarantined (sperm samples frozen) for at least 6 months (180 days), with the donor then retested for STI’s as described above and if the donor still tests negative, the specimen is released in the same manner required for anonymous-donor specimens per FDA regulations.  PREG would also highly recommend that legal paper work regarding potential responsibilities (if any) of the known donor to the offspring be clearly outlined and documented.

PREG does NOT allow the use of fresh semen for any donor inseminations.

 Sexually intimate couples

Although there is no FDA or legal requirement for sexually transmitted infection (STI) testing of sexually intimate partners undergoing fertility treatment, such testing can help to ensure that appropriate precautions are taken to minimize risk of STI transmission to partners and offspring. PREG does not perform inseminations using sperm obtained from men testing positive for HIV, Hepatitis B, or Hepatitis C. Couples in which one or both partners test positive for HIV, Hepatitis B or C should be treated by fertility centers having the appropriate laboratory resources.
Choosing a Donor Profile and Bank
There are several methods for matching the male partner with the donor. The couple should be encouraged to list the characteristics that they desire in a prospective donor, including race and/or ethnic group, height, body build, complexion, eye color, and hair color and texture.
Consideration should be given to blood type and Rh factor, particularly for Rh-negative recipients who have been previously sensitized (positive antibody screen against Rh antigen).  If the use of donor sperm creates the potential for Rh incompatibility, recipients should be informed of the obstetric implications of the condition.

PREG does not have a specific sperm bank that we require you to use. We recommend that you do an internet search for an FDA licensed and approved commercial sperm bank. Review the sperm bank’s website, contact their customer representatives, look at their donor profiles and carefully choose your donor. It may be helpful to contact several of the commercial sperm banks. Some of the different sperm banks used by our patients include Cryogenics Laboratories, Fairfax Cryobank http://www.fairfaxcryobank.com/, Xytex http://www.xytex.com/ , and California Cryobank http://www.cryobank.com/  (these are just some of the examples and are not meant to be an endorsement for any the companies and is certainly not an inclusive list).
We will ask you to contact the bank of your chosen donor and arrange to have the specimens sent to our laboratory for storage until you are ready for an insemination. The shipping should usually be done once you begin your menstrual period begins in the cycle that you are planning to be inseminated. Please only have one vial shipped at a time to PREG, as we have limited storage space for cryopreserved sperm. When ordering sperm, you may choose the intracervical (IC) grade sperm or “unwashed” specimens since we will “wash” all of the cryopreserved sperm samples prior to intrauterine insemination.  IUI grade (pre-washed) sperm can also be used, but usually costs more than unwashed specimens.  There will be a clinic charge for the insemination procedure at each insemination visit.  We recommend that you contact our financial representative at 864-232-7734 with any financial questions. She will be able to help determine your individual insurance coverage and the expenses for which you will be personally responsible.
Preparing for Insemination
Documentation and timing of ovulation:
It is important to establish your particular ovulatory pattern before proceeding with the actual inseminations. Women with regular cyclic menses are assumed to be ovulating. If you have irregular menstrual cycles, we may ask that you take your Basal Body Temperature (BBT) and use an ovulation predictor test for one or two cycles to determine your ovulatory pattern. Instructions for the predictor tests will vary with manufacturer and will be included in each kit. Questions can be addressed to the clinic nurse. There are several on the market, and we will do our best to keep you informed as to their availability, cost and correct use.  Remember that these tests are predictors of impending ovulation and your insemination is usually done the day after your ovulation test is positive.

When doubt exists about timing of ovulation, other tests of ovulation such as serum progesterone level, basal body temperature, luteinizing hormone (LH) surge detection, and ultrasound monitoring of follicular maturation can be used.  Appropriate timing of the insemination procedure optimizes chances for success. At PREG, we recommend ovulation monitoring with ovulation predictor kits and transvaginal ultrasound mid-cycle follicle scans to help time your inseminations. Women who do not conceive after several spontaneous cycle inseminations or who do not have regular ovulatory cycles may benefit from taking fertility medications, such as Clomid (Clomiphene) or Femara (Letrozole), to ensure optimal ovulation and improve their chance of conception. These fertility medications do have about a 10% risk of multiple gestations.  Use of other medications such as hCG 10,000 units or Ovidrel (these are a single injection or shot) may be recommended to trigger or boost ovulation and also help with the timing of your insemination.
Inseminations are done Monday through Sunday in our Greenville office only since our cryopreservation storage tanks are located in Greenville. Rarely, we may be unable to provide this service on weekends depending upon staffing. Patients should call the clinic at 864-232-7734 at the onset of menses to plan an insemination for that cycle including your ultrasound monitoring visit usually scheduled around cycle day 12. Please call our office and notify the infertility nurse before noon on Friday if you believe that you might have your luteinizing hormone (LH) surge over the weekend. They will be able to notify you if staffing will be available that weekend for a possible insemination.  On weekends, urine ovulation predictor tests should be done before noon on Saturday and if a positive test results on Saturday morning call our office at 864-232-7734, and the physician on call will be paged by our answering service and will give you instructions for a possible Sunday early morning donor insemination. For Sunday morning positive urine ovulation predictor kits, please call our office at 864-232-7734, and the physician on call will be paged by our answering service and will give you instructions for a Monday donor insemination.
Insemination
For donor inseminations, only frozen semen samples will be used. Basically, sperm freezing allows optimal screening of each donor for any sexually transmitted infections prior to the use of the sperm sample.  However, since frozen sperm is being used the pregnancy success rates are slightly lower than if a fresh sperm sample was to be used.  Again, with donor sperm only frozen sperm that has been previously tested and quarantined can be used for patient safety and according to FDA guidelines.  In general, pregnancy rates from donor sperm inseminations are around 10-15% success rate per cycle.  It is also important to know that pregnancy rates for normal, fertile couples are around 20% per month for comparison. 
The insemination is a relatively simple procedure that can be accomplished quickly with very little discomfort, similar to obtaining a Pap smear, and is performed in our office.  A small plastic catheter (tube) is used to insert the specimen (thawed sperm) into the uterine cavity through the cervix, allowing more motile sperm to travel into the fallopian tubes where fertilization of an ovulated egg could occur. A small amount of leakage or spotting can be anticipated after the procedure and does not reduce the effectiveness of the procedure. Once the IUI is completed you will rest on the exam table for 15 minutes and then go about your normal activities without limitations.  The IUI procedure is generally done only once per cycle (single insemination) since it can be timed to coincide with the release of your egg(s).  Double inseminations can also be performed (done the day before and day of ovulation) and can result in a slightly higher chance of pregnancy (3-5% more) but will result in twice the cost due to two inseminations and two donor sperm samples performed so it is generally not recommended.
What next after insemination?
We usually monitor your ovulation with a serum (blood) progesterone level 7-9 days after insemination to assess the adequacy of your ovulation. We request that patients call the clinic with the onset of menses following an insemination if pregnancy does not occur. This will help to determine if the timing of the insemination was correct and if changes should be made in future cycles. You will be usually scheduled for a urine pregnancy test in our office approximately 14 days after insemination and if positive, we will draw a quantitative blood pregnancy test to determine the actual level of your pregnancy hormone. Pregnancy tests are not recommended until 14 days after the insemination if no period has ensued. Earlier testing can give a false positive test if you received an Ovidrel or hCG injection to help time your ovulation.  We also advise patients to keep their daily routine as normal as possible and not allow their infertility to compromise the other meaningful aspects of their lives. We will certainly do our best to minimize your inconvenience and frustration. 
In addition, all females should be on a prenatal vitamin (prescription or over-the-counter) or taking at least 400 micrograms of Folic Acid daily.  We also advise you and your partner (due to second-hand exposure) not to smoke or use any tobacco products as well as no alcohol or illicit drug use while trying to get pregnant and certainly with pregnancy.  If you are on any prescription medications or herbal supplements, please inform your physician to clear for use with treatments and pregnancy.
Donor Intrauterine Insemination Costs if billed to your Health Insurance (if this is a covered benefit):
CPT code: 58322 Intrauterine Insemination    $190.00
89353 Donor Sperm Prep (Thaw & Wash)  $440.00
  58323 Sperm Count and Motility   $65.00
  76830 Transvaginal Follicle Scan   $250.00
  84144 Serum Progesterone Level   $92.47  
  99211 Monitoring Visit (Office visit)   $40.00
  36415 Venipuncture (Blood draw)   $20.00
  99000 Handling of Specimen    $10.00 

Self-Pay Costs (insurance not billed or no insurance coverage):
  Donor sperm prep and insemination:   $425.00
  Transvaginal Follicle Scan:    $160.00
  Serum Progesterone Level:      $95.00
  TOTAL SELF-PAY*      $680.00
  *Price also includes office visit, venipuncture and specimen handling

Medications* (approximate costs):  Clomid/Letrozole (Fertility drugs) - $40-50.00; hCG 10,000 units or Ovidrel (Ovulation triggering medications) - $40-50.00
Donor sperm samples*: $350-500.00 per vial (shipping charges may be extra)
*Costs may vary depending on place of purchase.