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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 (DI) 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
  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, and screening for hepatitis B and C, HIV, CMV and HTLV. 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 confirm that 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,HTLV,CMV 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.

There are a number of different commercially available Ovulation predictor kit available.

Some of these include CLEARPLAN, OVUQUICK, FIRST RESPONSE etc - all of which can be purchased from any pharmacy. Some of these kits may be expensive. On line companies may provide LH kits at more affordable prices.

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 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 down for 10- 15 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. Other activities such as intercourse are fine to do.

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 18 – 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 counselor before starting treatment.

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. 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.

Please read on for detailed information about Cytomegalovirus

CMV AND DONOR INSEMINATION

CMV is a virus that most adults have been exposed to and have immunity to. In healthy adults and children it produces mild cold or flu like symptoms for 1-2 weeks. Uncommonly it can cause a mild hepatitis (inflammation of the liver)  If a woman who has never had CMV becomes infected with the virus during pregnancy, the child is at risk for developing severe medical problems, such as mental retardation, deafness and seizures. You can be tested to determine if you have been exposed to CMV. If you are
CMV negative (meaning that you do not have antibodies against CMV), you should consider restricting your selections to CMV negative donors, to prevent the small chance of developing CMV during pregnancy and passing it the developing child. Information on the CMV status of all donors is available on their summary profile.

DETAILED QUESTIONS AND ANSWERS REGARDING CMV

WHAT IS CMV?

Cytomegalovirus, commonly called CMV, is a member of the herpes virus family that includes chicken pox, cold sores, and infectious mononucleosis (mono). The virus is carried by people and is not associated with food, water or animals. Most individuals are exposed to CMV in childhood and have a mild infection similar to a typical cold, while the immune system develops antibodies to fight the infection. The virus remains alive, but becomes dormant, or hides, inside certain cells for the rest of the person's lifetime.
Approximately 50-85% of adults will test CMV positive, confirming exposure. In developing countries, or areas of poor sanitation, this number is almost 100%. However, in a small number of individuals, the virus may reactivate and be transmitted in bodily fluids, such as semen. This is very common in people with immune suppression or individuals that have only recently been exposed to CMV.

WHAT IS THE DIFFERENCE BETWEEN CMV IgG AND IgM TESTS?

The CMV IgG test indicates previous exposure to CMV. The CMV IgM test indicates a recent or current infection, in which case all vials are discarded.

HOW IS CMV SPREAD? 

CMV is spread person-to-person by direct exposure to urine, saliva, mucus, cervical secretions, semen, blood, or breast milk. There is no vaccine for CMV. Daycare centers are one of the more common exposure settings, where children can transmit the virus through contact with each other's bodily fluids (infected children carry the virus in their respiratory and urinary tracts for long periods of time). Adults can also be infected through unprotected sexual contact. The production of virus may take place intermittently, without any detectable signs, and without causing symptoms. An infected mother can transmit CMV to her fetus either through the placenta or through exposure to her infected cervical secretions during birth.

WHAT ARE THE SYMPTOMS OF CMV INFECTION?

The symptoms are usually mild, non-specific, hard to detect, and resolve in 1-2 weeks.
An adult may not even realize that they have an infection. Some people develop a 'flu- like' illness with swollen lymph nodes or they may complain of feeling tired. As mentioned above, it can also sometimes cause a hepatitis, which may result in nausea, jaundice and fatigue. Children may have a runny nose. In people with impaired immune systems may develop a serious illness. Pregnant women who are infected for the first time during pregnancy usually recover completely with few or no symptoms. The unborn baby is at risk for congenital infection.

WHAT ARE THE SYMPTOMS OF A CONGENITAL CMV INFECTION?

If a pregnant woman has never been exposed to CMV and has her first infection during pregnancy, there is a chance that the fetus could become infected before the mother's body can eliminate the virus. Transmission to the fetus only occurs in a third of women who have a primary infection during pregnancy. Congenital CMV is the most common congenital infection in the US. Twenty percent of babies born with an infection develop medical complications over the first few years of life. Those symptoms can include low birth weight, deafness, blindness, mental retardation, small head, seizures, jaundice, brittle teeth and damage to the liver and spleen. While a child may develop some of the above symptoms, no baby develops all the symptoms and some infants have no symptoms at all.

HOW DO SPERM BANKS SCREEN DONORS?

Testing for antibody to CMV is performed on all donors. If the antibody test is negative or not detectable, the donor is presumed not to have been previously infected. Most
Sperm banks will then perform a new test every three months to monitor for new infections. If the donor tests positive for antibodies, additional testing is performed to determine if the positive antibody test represents a recent or old infection. If a recent infection cannot be ruled out, all suspect semen vials are discarded.

IS IT SAFE TO USE A DONOR WHO IS POSITIVE FOR CMV?

You may wish to consult with your own medical practitioner as to whether he or she feels it is acceptable to use a donor who is positive for CMV IgG antibodies. In most cases a donor who is positive for CMV IgG is non infectious. Furthermore, most Sperm banks have a six-month quarantine policy ensuring that should a donor test positive for a current or recent infection, all potentially infectious samples are not released.

WHAT DONORS MAY I USE IF I AM CMV NEGATIVE?

We would recommend that you use a CMV negative donor. However, you may use a
CMV positive donor, if you wish. While the risk is not zero, the chance of transmitting congenital CMV to a developing fetus from semen used at the time of conception is extremely low.

Hysterosalpingogram.(HSG)

The decision whether or not to have an HSG is entirely yours. We normally recommend it - only because doing DIs is an expensive business, and it is reassuring to know that your tubes are open and healthy prior to starting.
Please read below a detailed explanation of the procedure:
A hysterosalpingogram is a diagnostic x-ray that allows a study of your uterus and fallopian tubes.
Why is a HSG necessary?
It is done primarily to confirm that your fallopian tubes are open. However it also gives us information about the uterine cavity. It may for instance identify the presence of polyps or fibroids protruding in to the uterine cavity. These may potentially interfere with fertility.
Where is the HSG done – and by whom?
It is performed in an X ray department (usually within a hospital or clinic) by a radiologist.
When is the procedure done?
The timing of this test is very important. It needs to be performed early on in the menstrual cycle before the lining of the uterus becomes too thick and also before ovulation – to make sure that this test is not done at a time that you may conceivably be pregnant.
Therefore, the best time to do the HSG is before day 12 of your menstrual cycle. The
HSG cannot be done during your period. So there is only a small window of time every month that it can be done. (i.e. after your period is complete – but preferably before day
12 of your cycle)

Is an HSG painful?

The procedure itself may be a little uncomfortable. For this reason, you may want to take someone with you to the hospital. We would also suggest that you take two Advil or Tylenol approximately one hour before the procedure. You should be reassured that most patients have only minor cramping.

What are the risks of the procedure?

There is a small risk of infection, and for this reason it is important that you take prophylactic antibiotics. A 5- 7 day course of doxycycline (tetracycline) will be prescribed to you. Once you know the day of your procedure, you should start taking this antibiotic twice a day starting the day before. This is a commonly prescribed antibiotic, and side effects are uncommon. However, some side effects that may occur include diarrhea, nausea, and a skin rash if you go out in the sun. (Photosensitivity) It is important that you continue the antibiotics for the full five days. Apart from a small risk of infection, there is also a small risk of a reaction to the dye. It is important that you tell the radiologist if you have any specific allergies. Allergies that would be important to mention would be to shellfish, iodine, or a previous reaction to intravenous radiological contrast.

There is a drug commonly used in infertility called Metformin. It is very important that if you are on Metformin, you stop taking it the day before the procedure, and only restart it 5 days later. (You should NOT take metformin for the few days following an HSG – this may be potentially dangerous)

What is the process?
The hysterosalpingogram itself is done by injecting dye through your cervix, into your uterus, and out through your fallopian tubes. During the procedure, the radiologist will insert a small speculum into your vagina, a bit like having a pap smear. A very small catheter will then be passed through your cervix and the dye injected. X-rays will then be taken.
Are there other benefits to an HSG?
As mentioned above, this study is designed to tell us about the inside of your uterus and also to confirm whether your fallopian tubes are patent (open) and normal. However, although it is essentially a diagnostic test, there is also a beneficial effect. The contrast dye that is used has some detergent-like actions and helps flush out debris and bacteria from inside the fallopian tubes, and does indeed result in an improved fertility rate for the first few months afterwards.

What do I do after the test?

After the test, if you experience any pain, malodorous discharge, or fever, you should call the HART Fertility Centre right away. Please do not forget to complete the course of antibiotics that have been prescribed.
You should schedule an appointment to come in to HART to discuss this and other test results with us.
If I do not take the birth control pill for the HSG, can I try and conceive with this cycle? Yes you can. It is fine to continue to try and conceive while you are finishing your course of antibiotics.

What does it mean if one or both tubes are obstructed?

The results will be discussed with you. It is important to remember that the uterus is a muscle, and will cramp when dye is injected. This cramping may “pinch” off the entrance to the fallopian tube – and make it appear that one or both tubes are obstructed. This would be a false positive result. If the tubes appear to blocked close to the uterus, we would need to do a Laparoscopy to look at the tubes in more detail. This is a procedure done under general anaesthetic, so is not generally the “first line” investigation.
If the tubes are swollen and obstructed (hydrosalpinges) – it would indicate that the tubes have been previously damaged (usually by infection). The management would depend on a variety of other factors-, which would be discussed with you at HART.