Associate Director, REI, Weill Cornell Medical Center
Former President, ASRM
Reproductive Attorney, Law Office of Brian Esser
After finding donor sperm, there are two ways to become pregnant: artificial insemination or in vitro fertilization. In this lesson we’ll focus on artificial insemination.
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, which could make it harder for a non-carrying mother to be granted parental status.
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.
There are a few different permutations on how IUI can be done, but in general this is the simplest, least invasive method of conception for lesbian women, at least in a medical setting, and the one that has the lowest up-front costs.
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.
It’s common for people to say “IUI just doesn’t work,” but that observation may not apply to you.
For lesbian couples, IUI sucess rates are typically much higher than in a population being treated for infertility. IUI success rates for lesbian women can be up to 20% per cycle, and 50 - 70% after five 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 150 IUI cycles for lesbian 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 lesbian 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 to try multiple inseminations in back-to-back months.
Again, below is the cumulative IUI pregnancy rate data. The odds of success continue to climb with every successive IUI until the fifth to seventh IUI; but thereafter it becomes incredibly unlikely any future IUI will work. Around this point, it’s likely best for the patient and doctor consider IVF (which we’ll cover in the next lesson).
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 a heterosexual, infertile population, which isn’t ideal, but shows the progression 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% of delivering a child and if so, a 0 - 5% chance that birth 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, but if she does a 30% chance it will be with twins.
There’s the option to do a natural 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 heterosexual, 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, though, also increases, from the low single digits in a natural cycle to the low double digits with these drugs.
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 incredibly expensive (around $2,000 per cycle).
They moderately increase success rates above Letrozole or Clomid, but it’s rare that they would be recommended for IUI, because they are costly and substantially drive up the risk of multiple gestation pregnancy (nearly 1 in 3 pregnancies).
Many of the news-worthy stories of high order multiple pregnancies you may have read about were the result of combining gonadotropins and IUI.