From the book
How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
What is donor insemination ( TID) ?
What are the psychological issues raised by donor insemination treatment ?
Who are the sperm donors ?
How is the sperm frozen and stored in a sperm bank ?
What about using a known sperm donor ?
How is donor insemination treatment performed ?
Why is it safer to use frozen sperm samples for donor insemination ?
What is sperm banking ?
THERAPEUTIC INSEMINATION BY DONOR [TID] means using the sperm ( Sperm Video ) from an anonymous donor to achieve a pregnancy, and is a treatment option if the man is infertile. While TID is a well established method for treating male infertility, it can be very difficult for the couple to accept. With the newer options for treating male infertility, such as microinjection, the need for TID has declined. However, these new techniques can be very expensive, and because they are out of the reach of many couples, TID is still a viable option.
Getting set for TID
Before a couple choose TID as a treatment, they must remember the taxing ethical, emotional and psychological repercussions it has for both of them. The husband may feel threatened, isolated, inferior, insecure and jealous. He may wonder whether he will be able to play father to " another man's child ". In fact, with the advent of microinjection, coming to terms with TID has become even more difficult, since many men are forced to resort to TID rather than use microinjection with their own sperm ( Sperm Video ) , purely for financial reasons.
The woman may be resentful that she has to undergo treatment and turmoil for something that is not actually her "fault". She may also worry about bearing the baby of a total stranger ; and will often have no support as this is something which she may not be able to share with anyone - even her own mother.
Couples undergoing TID often undergo psychologic reactions which can be difficult to cope with. The sense of isolation is even more than with other forms of infertility, since most couples do not tell anyone they are undergoing AID - so that they miss the social support and sympathy which other infertile patients receive. The stress can be tremendous because the sperms of another man are being inseminated into the wife, and both partners experience many conflicting emotions. The involvement of a completely unknown third party as a sperm donor can make coping with the pregnancy especially difficult . Fantasies and nightmares may occur about the unknown donor - and there are also concerns as to whether the child will be normal and what the child will look like . Many men also experience sexual impotency at this time, but this is only temporary.
Now is the time to talk, for togetherness. Air out all your apprehensions with honesty and maturity. Discuss how you will make sure that you will both be equal partners in parenthood. She will have to reassure her husband with tact, gentleness and humour of her commitment to him. Love, patience and understanding are very important - this is a time when the couple needs each other the most. Seek counselling from your gynaecologist or fertility expert. Discuss other choices too. Don't rush into adopting a sperm ( Sperm Video ) - explore the alternative options as well!
Who are the donors?
The donors are healthy men between 20 to 40, from a sound background, and usually graduates. Those who are healthy, with no family history of illness are requested to provide a sperm sample for testing. This semen is analyzed, and accepted only if it has superior qualities: a count over 100 million per millimetre; and motility of 70% to 80%. Blood is checked to make sure they are negative for AIDS, Hepatitis and STDs.
After liquefaction, the semen sample is mixed with an equal quantity of the cryoprotectant medium ( a chemical which prevents the sperm from being damaged even at very low temperatures) and is loaded into plastic straws. These are uniquely coded and sealed; and then placed in steel tubs of liquid nitrogen where they are frozen to - 196 degree Celsius. One day later, one straw is removed and thawed to see how the sperms survived the cold ( cryosurvival). Only samples which contain at least 25 to 40 million motile sperm are accepted.
The sperms are then kept in cold storage for 6 months, which is how long it takes for the HIV virus ( which causes AIDS) to become detectable in a person's blood after infection. This is called the quarantine period. The donor's blood is then retested for HIV, hepatitis and STDs, and the infected donors weeded out.
Fig 1. Sperm being frozen in liquid nitrogen
Donors are paid a little more than conveyance costs - they are usually philanthropic men who have experienced fatherhood and want to make another couple happy. They are not allowed to produce more than 10 babies and the doctors generally scatter the offspring so that there is no risk of half siblings unwittingly marrying each other.
Sometimes couples wish to use a friend or relative as donor. However, there are many dangers in doing so. Over time, the donor's psychological make-up as well as the relationship with the donor may change. This could create social and legal problems. Furthermore, you will become dependent upon the donor's discretion to keep the insemination a secret. This is why using a known donor is not usually a good idea - however tempting this may seem.
The Treatment Process
The couple signs a consent form for TID after appropriate counselling. The doctor will need to ensure that at least one of the woman's fallopian tubes is open - and may advise a hysterosalpingogram or laparoscopy to confirm this.
The woman may be treated with fertility drugs to ensure ovulation. Daily vaginal ultrasound scans are done from the 11th day of the cycle to view the evolution of the egg and discover exactly when the maturing follicle bursts.
For frozen sperm , a straw of the appropriate donor ( who best matches the husband's physical traits) is picked out and rechecked under the microscope to see that the sperm are actively motile. The doctor matches the donor and the husband for height, build, hair colour, skin colour, eye colour, Rh factor and blood group.
Under sterile conditions, the donor sperm is injected through a plastic catheter into the cervix. The patient rests for about ten minutes and that's that. The husband is encouraged to be present at the time of the insemination - this is one way that both the partners can be close during the process ; and some clinics will even allow the husband to do the actual insemination himself, so he feels more "involved". There is no reason not to make love shortly after TID if this is what the couple wants to do.
After each insemination there is than a two weeks waiting period to find out if it's been successful. It's an emotional roller coaster - anticipation, insemination, menstruation, desperation, and then, hopefully - elation.
Success statistics mimic nature. They are 10% in a 25 year old woman in one cycle ; so that over six treatment cycles the chance of a pregnancy is about 60% in a 25 year old - and only about 20% in a 38 year old . It takes nature time to make babies, and patience is needed. The chances of success are highest if the female partner is young, has no fertility problem and the husband has no sperm. Irregular menstrual cycles; or a history of endometriosis or tubal infection decreases the chance of pregnancy. Interestingly, pregnancy rates with TID are lower in women whose husbands have a low sperm count, as compared to those whose husbands have no sperms at all . The reason for this is not entirely clear.
Once you get pregnant, your pregnancy is like a normal pregnancy - with the same risks of miscarriage and birth defects as any other. If you change your obstetrician , you do not even need to tell your new doctor that you have conceived by TID. He will never know; and the name on the birth certificate will be yours and your husband's. With TID strict confidentiality is maintained, and the identities of the patients and donors are kept secret. Historically, parents have kept TID a secret from the child and from friends and relatives. Unlike adoption, TID is not obvious to those who know the infertile couple. It is entirely up to the parents to tell the child the circumstances of his or her birth and most Indian doctors advice against it . However, there is always the burden of secrecy which the parents have to bear for the rest of their life.
The Donor Semen Sample - Fresh or Frozen?
Traditionally, gynecologists have used fresh semen samples (ejaculated recently} for TID. However, using fresh semen samples for TID can be hazardous to the patient's health. It is best to use frozen cryopreserved, tested samples from a sperm bank for TID. It used to be felt that pregnancy rates with frozen samples were poor as compared to fresh samples. However, recent studies have shown that if the frozen samples contain a sufficient number of motile sperm, pregnancy rates with fresh and frozen samples are comparable.
- to tell or not to tell friends and family
- the need to explain to employers and co-workers the need to arrive late, leave early, take time off - without being able to give a reason why
to deal with an erratic ovulation cycle caused by anxiety
- to keep your sexual relationship on an even keel
- to work out a plan when one partner wants TID and the other does not
Disadvantages of fresh semen
- There are no records of the donors and no information as to his medical and family history.
- It's impossible to match the physical traits of the donor and the husband.
- Using known donors can lead to rocky legal , emotional and ego problems.
- The quality of the sample is always suspect, but beggars can't be choosers.
- It could be difficult to produce a donor at the critical time and occasionally a treatment cycle has to run dry.
- The spectre of transmission of AIDS looms large since fresh semen cannot be tested for AIDS
Advantages of frozen sperm
- No risk of STD and AIDS as the samples are quarantined for three months and the donors are retested
- Around the clock availability; no scheduling bottle neck.
- High quality product since it is tested before and after freezing
- Rh negative donors can be used for Rh negative women
- Physical traits of husband and donor can be matched
While the major application of sperm banking today is for donor insemination, sperm banking is also useful in a number of other areas as well. Thus, we can store and freeze husband's sperm samples for treating the wife, and this is very useful in the following circumstances.
- When the husband has situational erectile dysfunction, so that he cannot produce a semen sample by masturbation at the appropriate time of an IUI or IVF cycle, storing a sample is very useful . This frozen sample can be used as a backup, in case the man cannot produce a sample at the required time. However, in many cases, because the man knows that a frozen sample is available , this helps to take the pressure off, so that many of them can produce a fresh sample with little difficulty!
- When the husband is away (working overseas or traveling), his frozen sample can be used to treat his wife.
- For men with very variable sperm counts, it can be helpful to store the "good samples", so that these can be used. Unfortunately, pooling many frozen samples together does not help to increase the sperm quality.
- For men with cancers, sperm freezing offers them a chance of conserving their reproductive potential.