Reproductive Attorney, Law Office of Brian Esser
Chapter Leader of Single Mothers by Choice Group, Single Mother by Choice
Associate Director, REI, Weill Cornell Medical Center
Former President, ASRM
For a woman who’s interested in having a child through fertility treatment, generally speaking there are three core options, with varying levels of cost, intensity, and success.
Almost invariably, this process will require women to think through the process of selecting a sperm donor, and we’ll later outline some of the tradeoffs for each treatment approach.
Before we delve further into a discussion of selecting sperm and fertility treatment, one important housekeeping note.
Throughout this guide, we’ll continually refer to “multiple gestation pregnancies” (like twins, triplets, or more), as a risk of certain fertility treatments.
As you can see below, there’s a higher risk of infant mortality and cerebral palsy in multiple gestation pregnancies, not to mention greater risks to the mother.
For this reason, we’ll continually discuss ways to minimize the risk of becoming pregnant with a multiple gestation pregnancy when laying out options.
Regardless of the type of treatment you decide to do (artificial insemination or IVF), it’s a good idea to start with a basic fertility evaluation. This could include blood tests to evaluate your hormone levels and a physical exam looking for any concerns in your uterus or fallopian tubes. You may also consider completing genetic testing for yourself. The results may have an impact on your treatment decisions. For more information on fertility diagnostic testing, see our dedicated course.
Let’s start with the process of selecting donor sperm because regardless of which path (at-home insemination, IUI or IVF) a woman takes, proccuring sperm is a crucial step.
The person who provides the sperm is referred to as a “donor” though, counter-intuitively, they usually get paid. We characterize donors into three buckets:
While there are many decisions to be made here, we think of there being two primary ones, namely:
Will you procure sperm from someone you know or from a sperm bank?
If using a bank, do you want your child to one day know that donor’s identity?
A known sperm donor is typically someone who is in the life of the solo-mother-to-be. This could be a friend or an acquaintance.
There are lots of positives to using a known donor.
First, you’ll have a good sense of who this person is—they’ve been personally vetted by you. This matters because, as you’ll see with donors from sperm banks, many women feel they’re given limited information and can’t formulate a sense for what kind of person the donor is.
Second, you can also take extra steps that make you feel more comfortable with this donor, like ordering specific genetic screening that you want performed. This matters because many patients wonder whether sperm banks do a thorough job medically vetting their donors (more on this in a second).
Third, using a known donor also minimizes the risk of surprises later, like learning this same donor has fathered 50+ children who are genetic siblings to your child.
Fourth, you can create a unique family structure, whereby a known donor can also be a part of a child’s life from early on if that’s what the mother wants.
Fifth, it’s typical to need more sperm than expected. That’s because fertility treatments seldom work the first time and because many parents want more than one child. Many women who acquire sperm from a bank come to learn it’s hard to get ongoing specimens from a donor they like. A known donor is more likely to be able to provide additional samples when needed.
Sixth, presumably the sperm from a known donor can be acquired more cheaply than through a sperm bank, however this will likely be counterbalanced with a few additional costs.
Seventh, unlike sperm sourced from a sperm bank, known donors can contribute fresh samples (compared with sperm banks which only offer frozen samples). In treatments like IUI, this delivers better results, as you can see below.
Of course, there are also drawbacks to using a known donor.
Most importantly, there can be legal risks, especially if the donor has involvement with the child. Some of these risks can be mitigated through legal agreements and making sure to do the insemination at a clinic so that it’s well documented that they’re a donor, not a father.
Second, there can be complications if, down the road, you and the donor don’t see eye-to-eye on what the relationship should be between the child and the donor.
Next, you’ll likely need to contend with a number of logistical hurdles that can delay treatment. These include psychological counseling and evaluation for you and the donor, and clinics requiring that such sperm be quarantined for a period of time to protect moms from communicable diseases like STDs.
Lastly, you’ll likely need to cover the costs to have the donor’s sperm tested and his physical and mental health assessed, and possibly any costs he accrues for attorneys to review documents relinquishing any claims of parentage to the child. These costs may supersede the cost of having simply purchased sperm from a sperm bank.
The alternative to using sperm from someone in your life is to procure sperm from a sperm bank. Here we’ll try to clarify how this process works as well as the tradeoffs in comparison to using a known donor.
In many countries, there are a handful of larger sperm banks (200–500 donor sperm available at any one time) and a few smaller sperm banks.
Often, banks operate as a network, establishing recruitment centers near large, state-run universities where they screen candidates (medically and psychologically) before collecting their sperm.
If selected, donors waive their paternal rights, agree to testing, provide several samples, and create an online profile for customers of the bank to review.
The costs of using a sperm bank vary, and prices between the major banks range by 10%–15%. There are really two costs: the cost of information and the cost of sperm itself.
Information: You should assume you’ll pay for varying tiers of information on donors on the sperm bank’s portal, with top tier access in many countries running $250 every three months.
Sperm: The costs to acquire a vial of sperm range from $500–$1,000, and rise if:
The donor is willing to have their identity known by the offspring when they turn 18 (this is known as an “open” donor)
The sample has been washed and treated before it is shipped out
For context, the average number of vials each woman will use for an IUI treatment is 3–7 in total and the costs of sperm rise 4%–10% per year.
Ultimately, since fertility treatment can be inefficient (sperm gets used up quickly), customers find they need more sperm than they expected. These customers often regret not buying more sperm (of a donor they like) earlier, because donors eventually stop providing samples and other customers may have stepped in and bought all that was left.
First, compared with trying to select a known donor (which we addressed in the sections above), sperm banks provide a broader selection of donor sperm to choose from (though many customers complain they find it hard to find what they’re looking for). What’s more, you can get access to the sperm almost immediately.
Second, sperm banks handle much of the logistical hassle that falls to those using a known donor: in this case physical, psychological, and medical screening has been handled by the bank. Additionally, the donor has waived all rights and claims to the child.
Third, most sperm banks are highly single mother friendly, as this group comprises a big portion of their business.
First, the experience of finding a sperm donor through a bank can be painfully inefficient. While banks claim to reject 90% of applicants who apply to become donors, many customers find the volume of donors to be overwhelming and the quality to be underwhelming.
Second, sperm banks make little information available to customers. Customers want to see adult photos while banks usually just supply younger photos of the donor. Personal essays are penned by 18 and 19 year olds, and leave customers to wonder what this person will be like as a fully-formed adult. Specific schools attended are purposely made vague because they are not always viewed as “elite” institutions.
Third, many worry that banks often know less about their donors than customers are led to believe. While banks are meant to follow FDA and ASRM screening guidelines, standards vary between banks and sometimes even within the same bank ranging from recruitment center to recruitment center.
The headline below profiles a case where a sperm donor was advertised as having a 160 IQ and a PhD but was later revealed to have neither—instead he had been convicted of burglary and diagnosed with schizophrenia before donating. His samples were used to father 23 offspring and were obtained from a large bank that services clients globally and that’s historically been considered reputable.
Fourth, sperm banks provide frozen sperm. Frozen sperm carries lower rates of success than fresh sperm, as shown above in the case of IUI. Fresh sperm can only be provided by a known donor.
If you choose to get sperm from a bank, the next major decision is often whether you’d prefer to buy sperm provided by an “open” donor or from an “anonymous” donor (which will cover in the next chapter).
An open donor has agreed to have his identity made available to the child when the child turns 18 years old. Alternatively, an “anonymous” donor has instructed the sperm bank never to release his identity to the offspring.
In making this decision, women will want to think through their feelings about their future children (as adults) having the option to reach out to the sperm donor.
A sperm bank recently made data available on what percentage of adult offspring actually follow up to request access to their sperm donor’s identity.
As you can see, children of single parents requested their donor’s identity 58% of the time. It reflects the very real possibility if you elect for an open donor, your child will take advantage of the information available to them.
Of those who requested information, the primary motivation was to get “more information with reference to self,” namely what traits do they share in common with the donor. Most respondents eventually planned to make contact with the donor and over 90% of donors said they’d be open to reciprocating contact. Nearly 90% of the adult offspring said they harbored “no or low” expectations for what might arise from such interactions.
Similarly to an open donor, an anonymous donor provides sperm to a sperm bank.
However, they do not consent to let the adult offspring learn their identity. Roughly 60%–70% of donors to sperm banks today are listed as anonymous.
There is a very real question as to whether preserving the donor’s “anonymity” is realistic with the advent of consumer genetic testing.
There’s an ever increasing chance that in the future, if your child really wants to find out about their paternal genetic heritage, they’ll be able to use services like 23andMe or Ancestry and ultimately learn the identity of their sperm donor. Within minutes, using social media, they may be in touch–allowing little time for a planned, lucid weighing of the positives and negatives of making contact.
Given this donor explicitly decided to remain anonymous, there’s a real possibility such an interaction might not go well with obvious negative implications for everyone involved.
After finding donor sperm, there are two ways to become pregnant: artificial insemination or in vitro fertilization (IVF). In this lesson we’ll focus on artificial insemination and cover IVF in the next.
For at-home inseminations, people often use an over-the-counter tool to place sperm in the vagina (technically referred to as intra-vaginal insemination). There isn’t great data about the efficacy of intra-vaginal insemination, so as a proxy, we’ll share the data collected on intra-cervical insemination, which we can assume is a bit more effective than intra-vaginal insemination.
This is the process where sperm is placed near a woman’s cervix and the procedure can be performed at home. While there are certainly positives to at-home insemination (lower cost and more convenient), success rates tend to be lower when compared to the more popular alternative, intrauterine insemination (more expensive and performed at a clinic).
What’s more, doing an at-home insemination with sperm from a known donor creates complexities including a more difficult pathway to legally demonstrating that a donor has no rights to the child.
During intrauterine insemination (IUI), sperm is deposited further along the female reproductive tract. This has the advantage of improving the odds of sperm reaching the fallopian tubes to fertilize an egg (hence the higher rates of success). The disadvantage of IUI is that it must be performed in a medical setting.
That said, IUI can still require a fair amount of time at a doctors office, and the costs can add up. The cost of an IUI cycle can range from $500 to $4,000 and depends on which, if any, medications are taken in the lead-up to the insemination.
We have an incredibly detailed course on IUI here, that we suggest you look at if this becomes an option you want to consider.
It’s common for people to say “IUI just doesn’t work,” but that observation may not apply to you.
For single women, IUI success rates are typically much higher than in a population being treated for infertility. In the below study, IUI success rates for single women average around 35% after 5 or so IUI cycles.
However, these success rates are highly dependent on age. As you can see from the data below, success rates go down significantly from ages 35 on. This data was collected and aggregated from 500 IUI cycles for single women; a smaller sample size than we’d like to have, but it’s the most that’s been published in a credible journal.
Yet, even for a single woman under the age of 35, the odds are likely that any given IUI will not work. This can be a devastating surprise and so it’s important to get familiar with the odds of success for IUI.
Given the single-cycle failure rate for IUI, it’s common for women to try multiple inseminations in back-to-back months.
IUI success rates and costs vary depending on which, if any, medications are used leading up to an insemination.
The chart below has data from an infertile population (admittedly not ideal for this course) and shows the correlation of increasingly intensive drugs, higher success rates, but also higher risks (in the form of multiple gestation pregnancies).
To illustrate, if an infertile woman does IUI with no drugs, she may have a 5%–10% chance of delivering a child and if so, a 0%–5% chance that delivery will result in twins. On the other hand, if a woman takes gonadotropin (injectable hormones) leading up to her IUI, there’s a nearly 15% chance she’ll deliver, and if she does, an extremely high 30% chance it will be with twins.
There’s the option to do a “natural” IUI cycle, and use no drugs at all, in which case you’ll merely do monitoring to understand when ovulation is likely, and have the insemination performed just before ovulation.
The best candidates for this are women with “regular cycles”, meaning they have no ovulatory disorders.
In the data from infertile couples above, these natural cycles had the lowest chances of working, but also the lowest risk of resulting in a multiple gestation pregnancy like twins, triplets, or more.
The next level up are the medications most commonly used with IUI. These are oral medications like clomiphene (Clomid) or letrozole (Femara). These medications are fairly easy to take, inexpensive, and they do boost success rates per cycle into the low teens.
However, the chances that a resulting pregnancy is a multiple gestation pregnancy also increases.
Finally, taking these medications will probably step up the logistics involved in a cycle, because it’s more likely that your doctor will have you come in for monitoring appointments to ensure the medications are working properly—this is more time consuming and also adds some cost.
Generally speaking, many doctors are comfortable performing an IUI with these drugs: they feel the improved odds of success compensate for the increased (but still “tolerable”) risk, cost, and inconvenience.
Finally, the most intensive medications are gonadotropins—these are injections that are expensive (around $2,000 per cycle in some countries like the US, and far less in most other regions).
They moderately increase success rates above Letrozole (also known as Femara) or Clomid, but it’s rare that they would be recommended for IUI, because they are often more costly and substantially drive up the risk of a multiple gestation pregnancy (nearly 1 in 3 pregnancies).
Many of the newsworthy stories of high order multiple pregnancies you may have read about were the result of combining gonadotropins and IUI.
IVF, or in vitro fertilization, is a more intensive and expensive treatment option than IUI—it requires that eggs are surgically removed from the ovaries, that those eggs are inseminated with sperm in a laboratory, and that a resulting embryo is placed in a woman’s uterus with the hopes that it implants and leads to a healthy baby.
A single woman might strongly consider IVF if:
Generally speaking, IVF success rates vary by age. If a woman has an underlying fertility issue, as you can see below, the cumulative odds of success vary dramatically.
More than half of women under age 40 deliver a child after 3 IVF cycles, whereas for women over the age of 40, rates of IVF success tend to be much lower.
The above data reflects success rates for couples with an underlying fertility issue.
A better analogue for single women might be IVF success for women with no underlying fertility issue and who underwent treatment (using donor sperm) on account of their partner’s male factor infertility issues. The below chart reflects data from all couples meeting this criteria treated in the UK from 2003 to 2010. As you can see below, after 3 cycles, roughly 70% delivered a child. Unfortunately, the study data is not broken out by age.
IVF is a complex process with myriad decisions going into a single cycle. We’ll summarize it below, but if you want the full set of details, head to our comprehensive guide to IVF here.
A woman is usually given injectable hormones to make her ovaries develop as many eggs as they can (say, 8–20) instead of the usual 1–2 that would be matured each month. This continues for an average of 10 days, until a “trigger shot” is taken to start the ovulation process where eggs become mature.
Eggs are surgically retrieved from the ovaries, and typically general anesthesia is used during the procedure. A doctor usually uses a vaginal ultrasound to guide a needle that suctions out each egg.
Over the next 3–7 days, a fertility clinic’s laboratory will take all of the collected, mature eggs and try to grow them into healthy embryos.
First, they fertilize the eggs with sperm either by surrounding an egg with sperm in a petri dish, or using ICSI, a micro-procedure where a single sperm is injected into an egg. If you’re using frozen donor sperm, there’s a good chance your doctor will want to use ICSI.
Then the laboratory will try to grow the embryos into either Day 3 “cleavage stage” embryos or heartier Day 5, 6, or 7 “blastocyst stage” embryos.
Once embryos have reached the blastocyst stage, there is an option to remove a few cells and have them sent out for genetic testing, sometimes referred to as PGT or PGS screening. This testing can either test for a single genetic disorder that runs in your family history or testing can predict if an embryo is likely or unlikely to lead to a healthy pregnancy.
As you can see, implantation rates per embryo transfer are higher with PGT-tested and approved embryos than they are with untested embryos and are less likely to lead to a miscarriage.
In some regions and at some clinics, you may be able to learn the genetic sex of the embryo. Some see this as a positive in terms of family planning.
That said, experts disagree on the utility of PGT-screening. We go into more detail on the topic to help you make your decision in our dedicated course here.
After developing embryos, whether or not genetic screening has been done, more clinics and patients are using the option to freeze all of their embryos. Then embryos will be transferred later on.
An embryo will be transferred into the uterus, with the hopes that it “implants” and leads to a healthy pregnancy. The safest option is to transfer one embryo at a time.
Any embryos of reasonable quality that were not transferred will be frozen and can be used later, either in the event that the first transfer doesn’t work, or if it does work, for more children in the future.
In some senses, you can think of IVF like a funnel. Unfortunately, not every developed ovarian follicle will contain a mature egg, and not every mature egg will lead to a healthy embryo or a baby. At each stage throughout the process, you’ll lose something. That’s why the goal is to have a high number of eggs to start off with. Below is a sample summary of this funnel.
If a woman is not producing enough high quality eggs to make IVF a success, she can use eggs from an egg donor (see ouur detailed course here) to bolster the odds of success. See below how the cumulative odds of IVF success surge for women using donated eggs compared with women age 42 using their own eggs.
Typically IVF costs around $20,000 per cycle in the US and global prices vary (e.g. nearly free in some Nordic countries, $5,000 in mainland China), often significantly more than the prices clinics advertise. That’s because marketed prices seldom include the cost of (non-optional) medication (~$5,000 per cycle in the US) or costly add-ons the clinic will eventually insist upon (e.g. ICSI fertilization if you use frozen sperm).
In the US generally, it’s rare to have IVF covered by an employer’s insurance plan. For single women, though, it’s truly rare.
That’s because most employers who cover IVF specifically have plans that have a “pre-authorization” requiring that a hopeful patient meet the medical definition of “infertility”—that means having unprotected sex for six to twelve months without success. Since many single mothers by choice haven’t aimed to build a family in that way, they’re often excluded from coverage and asked to pay out of pocket.
If you’re looking for our list of companies that cover fertility treatments, including those that offer policies that don’t require medical infertility, check out our workplace index here.
Outside of the US, IVF costs and coverage for single women vary. In many countries, a woman will be asked to try multiple (less expensive) IUIs before IVF can be covered. In other regions, governments will not cover any costs (IUI, IVF or otherwise) to help a single woman conceive.
We think there are a handful of criteria in determining whether a single woman should start with IUI or IVF. We elucidate the factors below, though of course prioritizing those factors is a personal choice.
In most countries, IUI is far less costly than IVF (e.g. $500 to $4,000 for IUI vs. $20,000 for IVF in the US), it’s less time intensive, invasive, and far less demanding (no surgery and probably no injectable hormones). Success rates with IUI aren’t as high as IVF success rates, but, for single women they can be respectable (up to 50% after 5 cycles for women under age 35).
IVF offers higher rates of success in a shorter period of time. IVF also has features that can help reduce the chances of miscarriage (e.g. a test called PGT or PGS, which carries additional cost) and the risks of conceiving a multiple gestation pregnancy.
If you agonized over the decision of a sperm donor, and you were only able to acquire a limited number of vials, you might want to consider that IVF uses sperm more efficiently, and that the option of freezing extra embryos from a cycle could mean that you can have more children later on with the same donor.
Age and time to pregnancy may be important if you are over 35 and if you are hoping to have more than one child. For example, a woman in her late 30’s or 40’s who wants to have multiple children might want to skip IUI. IUI could use up precious time before her fertility further declines, and IVF gives the option of banking embryos to have a child now and also more in the future.