Donor IUI is equally effective for heterosexual couples, single women and lesbians, but autologous IUI does worse.

STUDY QUESTION: Are there differences in the clinical outcomes of IUI among different populational groups (heterosexual couples, single women and lesbian couples)? SUMMARY ANSWER: The outcome of donor IUI (D-IUI) is similar in all populational groups and better than that seen with autologous insemination. WHAT IS KNOWN ALREADY: A vast body of literature on clinical outcome is available for counselling heterosexual couples regarding decisions related to ART. The reproductive potential of single women, lesbian couples and heterosexual couples who need donor semen is assumed to be better, but there is a scarcity of data on their ART performance to actually confirm it. STUDY DESIGN, SIZE, DURATION: In this retrospective multicentric cohort study, a total of 7228 IUI treatment cycles performed in 3807 patients between January 2013 and December 2016 in 13 private clinics belonging to the same reproductive medicine group in Spain were included. Patients with previous IUI attempts were excluded from the study. Only 1.9% of cycles were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 5318 D-IUI cycles were performed in three different populational groups: heterosexual couples (D-HC, 1167 cycles), single women (SW, 2839 cycles) and lesbian couples (LC, 1312), while a total of 1910 autologous IUI cycles were performed in heterosexual couples (A-HC). This last one was considered the control group and was composed of cycles performed in couples with a male partner with sperm parameters equivalent to those requested from donors. In order to identify factors with an impact on clinical outcome, a multivariate logistic regression analysis was performed. Regarding live birth rate (LBR), mixed effect models were employed to control for the fact that different patients were submitted to different numbers of treatments. MAIN RESULTS AND THE ROLE OF CHANCE: Parameters that were significant to the primary outcome (LBR) according to the multivariate analysis were the populational group (D-HC, SW, LC and A-HC) to which the patient belonged, female age and a diagnosis of low ovarian reserve. At the age range of good prognosis (≤37 years), LBR was similar in all groups that underwent D-IUI (18.8% for D-HC, 16.5% for SW and 17.6% for LC) but was significantly lower in the autologous IUI (A-HC) group (11%). For all these significant findings, the strength of the association was confirmed by P values <0.001. From 38 years of age on, no significant differences were observed among the populational groups studied, and for all of them, LBR was below 7% from 40 years of age on. LIMITATIONS, REASONS FOR CAUTION: To the best of our knowledge, a smoking habit was the only known factor with a potential effect on ART outcome that could not be controlled for, due to the unavailability of this information in a significant percentage of the clinical files studied. Our study was not capable of precisely quantifying the impact of a diagnosis of low ovarian reserve on the LBR of both IUI and D-IUI, due to the number of cycles performed in patients with such diagnosis (n = 231, 3.2% of the total). WIDER IMPLICATIONS OF THE FINDINGS: For the first time, a comparison among D-HC, SW, LC and A-HC was performed in a study with a robust sample size and controlling for potential sources of bias. There is now sound evidence that equivalent clinical outcome is seen in the three groups treated with donor semen (D-HC, SW and LC). Specifically, regarding the comparison between SW and LC, our findings rule out differences in LBR proposed by previous publications, with very similar clinical outcomes within the same age ranges. At age ranges of good prognosis (≤37 years), reproductive performance of D-IUI is significantly better than that seen in heterosexual couples undergoing autologous IUI, even when only cases of optimal sperm quality are considered in this last group. This finding is in agreement with the concept that, as a group, A-HC are more prone to have female factor infertility, even when their infertility assessment finds no contraindication to IUI. Age affects all these groups equally, with none of them reaching a 7% LBR after the age of 40 years. Our findings will be useful for the counselling of patients from the different populations studied here about ART strategies. STUDY FUNDING/COMPETING INTEREST(S): None.

Intrauterine insemination versus intracervical insemination in donor sperm treatment.

BACKGROUND: The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI). OBJECTIVES: To compare the effectiveness and safety of intrauterine insemination (IUI) and intracervical insemination (ICI) in women who start donor sperm treatment. SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL in October 2016, checked references of relevant studies, and contacted study authors and experts in the field to identify additional studies. We searched PubMed, Google Scholar, the Grey literature, and five trials registers on 15 December 2017. SELECTION CRITERIA: We included randomised controlled trials (RCTs) reporting on IUI versus ICI in natural cycles or with ovarian stimulation, and RCTs comparing different cointerventions in IUI and ICI. We included cross-over studies if pre-cross-over data were available. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane. We collected data on primary outcomes of live birth and multiple pregnancy rates, and on secondary outcomes of clinical pregnancy, miscarriage, and cancellation rates. MAIN RESULTS: We included six RCTs (708 women analysed) on ICI and IUI in donor sperm treatment. Two studies compared IUI and ICI in natural cycles, two studies compared IUI and ICI in gonadotrophin-stimulated cycles, and two studies compared timing of IUI and ICI. There was very low-quality evidence; the main limitations were risk of bias due to poor reporting of study methods, and serious imprecision.IUI versus ICI in natural cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in natural cycles (odds ratio (OR) 3.24, 95% confidence interval (CI) 0.12 to 87.13; 1 RCT, 26 women; very low-quality evidence). There was only one live birth in this study (in the IUI group). IUI resulted in higher clinical pregnancy rates (OR 6.18, 95% CI 1.91 to 20.03; 2 RCTs, 76 women; I² = 48%; very low-quality evidence).No multiple pregnancies or miscarriages occurred in this study.IUI versus ICI in gonadotrophin-stimulated cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in gonadotrophin-stimulated cycles (OR 2.55, 95% CI 0.72 to 8.96; 1 RCT, 43 women; very low-quality evidence). This suggested that if the chance of a live birth following ICI in gonadotrophin-stimulated cycles was assumed to be 30%, the chance following IUI in gonadotrophin-stimulated cycles would be between 24% and 80%. IUI may result in higher clinical pregnancy rates than ICI (OR 2.83, 95% CI 1.38 to 5.78; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). IUI may be associated with higher multiple pregnancy rates than ICI (OR 2.77, 95% CI 1.00 to 7.69; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). This suggested that if the risk of multiple pregnancy following ICI in gonadotrophin-stimulated cycles was assumed to be 10%, the risk following IUI would be between 10% and 46%.We found insufficient evidence to determine whether there was any clear difference between the groups in miscarriage rates in gonadotrophin-stimulated cycles (OR 1.97, 95% CI 0.43 to 9.04; 2 RCTs, overall 67 pregnancies; I² = 50%; very low-quality evidence).Timing of IUI and ICIWe found no studies that reported on live birth rates.We found a higher clinical pregnancy rate when IUI was timed one day after a rise in blood levels of luteinising hormone (LH) compared to IUI two days after a rise in blood levels of LH (OR 2.00, 95% CI 1.14 to 3.53; 1 RCT, 351 women; low-quality evidence). We found insufficient evidence to determine whether there was any clear difference in clinical pregnancy rates between ICI timed after a rise in urinary levels of LH versus a rise in basal temperature plus cervical mucus scores (OR 1.31, 95% CI 0.42 to 4.11; 1 RCT, 56 women; very low-quality evidence).Neither of these studies reported multiple pregnancy or miscarriage rates as outcomes. AUTHORS' CONCLUSIONS: There was insufficient evidence to determine whether there was a clear difference in live birth rates between IUI and ICI in natural or gonadotrophin-stimulated cycles in women who started with donor sperm treatment. There was insufficient evidence available for the effect of timing of IUI or ICI on live birth rates. Very low-quality data suggested that in gonadotrophin-stimulated cycles, ICI may be associated with a higher clinical pregnancy rate than IUI, but also with a higher risk of multiple pregnancy rate. We concluded that the current evidence was too limited to choose between IUI or ICI, in natural cycles or with ovarian stimulation, in donor sperm treatment.

Clomiphene Citrate versus Letrozole for Ovarian Stimulation in Therapeutic Donor Sperm Insemination.

AIM: To compare clomiphene citrate (CC) and letrozole for ovarian stimulation (OS) in therapeutic donor sperm insemination (TDI) cycles. METHODS: Retrospective cohort study between January 2011 and June 2014 at a University-affiliated private IVF clinic in Montreal, Canada. 257 normo-ovulatory women ≤40 years of age with no history of infertility undergoing 590 TDI cycles in the absence of a male partner (single women and same-sex couples) or azoospermia were included. Patients received 100 mg CC daily (145 women, 321 cycles) or letrozole 5 mg daily (112 women, 269 cycles), from days 3 to 7. Only the first 3 cycles were included per patient. Our main outcome measure was cumulative live birth rates (LBR). RESULTS: Baseline characteristics were comparable between the 2 groups. There were no differences in LBR per cycle (16.5% (53/321) vs. 11.5% (31/269), p = 0.08) and cumulative LBR (36.6% (53/145) vs. 27.7% (31/112), p = 0.13), between CC and letrozole, respectively. Multiple pregnancy rate (11.6% (8/69) vs. 8.7% (4/46), p = 0.6) and miscarriage rate (21.7 vs. 21.7%, p = 1) were also comparable between CC and letrozole, respectively. CONCLUSION: In normo-ovulatory women undergoing TDI, OS with CC or letrozole resulted in similar live birth and twin pregnancy rates.

The End of Anonymous Sperm Donation in Colorado: A Step Forward to a New Fertility Future in the US?

This Viewpoint discusses the new Colorado law prohibiting anonymous gamete donation and other debates over reproductive technologies and secrecy.

Standards in reporting cryopreserved donor sperm characteristics: should they be reported post-thaw or post-wash?

An increase in the reliance on imported donor samples has been the consequence of a continued shortage of UK donors. Disputes can arise between suppliers and purchasers if the sperm quality is not as expected, yet there appears to be no requirement for the standardization of methods for sperm processing or analysis. Following analysis of 102 donor intrauterine insemination cycles, this study demonstrates that the motile sperm concentration is significantly (P < 0.05) reduced after the necessary removal of cryoprotectant before insemination. Suppliers of donor spermatozoa should therefore provide information on standards used for sperm assessment and whether analysis is performed before or after washing in order that purchasers are better informed about the quality of the end product they are committed to buying.

Relationship between donor sperm parameters and pregnancy outcome after intrauterine insemination: analysis of 2821 cycles in 1355 couples.

The aim of this study was to investigate whether sperm parameters can affect the pregnancy outcome of artificial intrauterine insemination with cryopreserved donor spermatozoon (AID). A total of 1355 couples received 2821 AID treatment cycles in the Reproductive Medicine Center of the Tongji Medical College between January 2010 and December 2013, and the data were collected and retrospectively analysed. The relationship between pre-freezing, post-thawing as well as optimised sperm parameters and AID pregnancy outcome was investigated. Clinical pregnancy rate and cumulated pregnancy rate were also calculated. A total of 728 cycles from 2821 treatment cycles achieved pregnancies, and cumulated pregnancy rate was 25.81%. Pre-freezing progressive sperm motility in pregnant cycles was higher than that in nonpregnant cycles (P = 0.001); logistic regression analysis also indicated that pre-freezing progressive sperm motility was the only parameter affecting pregnancy outcome (P = 0.0001). Our study also showed that the cumulated pregnancy rate increased progressively and reached a plateau after the fifth cycle. In conclusion, pre-freezing progressive sperm motility should be a valuable predictor for AID pregnancy outcome. Female fertility factors should be considered, or IVF/ICSI should be recommended when couples received more than 5 AID cycles without pregnancy.

[Influence of artificial insemination with donor sperm on the pregnancy outcomes and safety of the offspring].

OBJECTIVE: To investigate the factors influencing the pregnancy outcomes of artificial insemination with donor sperm (AID), improve the pregnancy rate, and evaluate the safety of the offspring. METHODS: We retrospectively analyzed 7,761 cycles of AID for 5,109 infertile couples performed between July 1, 2005 and June 30, 2013 in the Center of Reproductive Medicine of Shenyang No 204 Hospital, the outcomes of pregnancy, and the incidence of birth defects. RESULTS: Totally, 2 252 clinical pregnancies were achieved by AID, in which the pregnancy rate per cycle was 29. 02% and the cumulative pregnancy rate was 44. 08%. The clinical pregnancy rate was remarkably higher in the females of ≤ 35 years than in those of > 35 years old (30.31% vs 20.18%, P < 0.01), in the women with < 5-year infertility than in those with > 5-year infertility (30.83% vs 28.16%, P < 0.01), and in the patients of the ovarian stimulation group than in those of the natural cycle group (33.22% vs 28.68%, P < 0.01) The clinical pregnancy rate was the highest in the first treatment cycle (29.87%), with statistically significant difference from the fourth cycle (23.61%) (P < 0.05), but not between the other cycles (P > 0.05). There were 28 cases of birth defects in the offspring (1.40%), including 6 cases (21.43%) involving the cardiovascular system, 4 (14.29%) involving the musculoskeletal system, 3 (10.71%) involving the urogenital system, 3 (10.71%) involving the central nervous system, 2 cases (7.14%) of cleft lip and palate, 2 (7.14%) involving the respiratory system, 2 (7.14%) involving the gastrointestinal digestive system, and other anomalies. CONCLUSION: Female age, infertility duration, and ovarian stimulation treatment are important factors influencing the clinical pregnancy rate of AID. Artificial insemination with cryopreserved donor sperm does not increase the incidence of birth defects, which is considered as a relatively safe technique of assisted reproduction.

Intrauterine insemination or intracervical insemination with cryopreserved donor sperm in the natural cycle: a cohort study.

STUDY QUESTION: Does intrauterine insemination in the natural cycle lead to better pregnancy rates than intracervical insemination (ICI) in the natural cycle in women undergoing artificial insemination with cryopreserved donor sperm. SUMMARY ANSWER: In a large cohort of women undergoing artificial insemination with cryopreserved donor sperm, there was no substantial beneficial effect of IUI in the natural cycle over ICI in the natural cycle. WHAT IS KNOWN ALREADY: At present, there are no studies comparing IUI in the natural cycle versus ICI in the natural cycle in women undergoing artificial insemination with cryopreserved donor sperm. STUDY DESIGN, SIZE, DURATION: We performed a retrospective cohort study among all eight sperm banks in the Netherlands. We included all women who underwent artificial insemination with cryopreserved donor sperm in the natural cycle between January 2009 and December 2010. We compared time to ongoing pregnancy in the first six cycles of IUI and ICI, after which controlled ovarian stimulation was commenced. Ongoing pregnancy rates (OPRs) over time were compared using life tables. A Cox proportional hazard model was used to compare the chances of reaching an ongoing pregnancy after IUI or ICI adjusted for female age and indication. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included 1843 women; 1163 women underwent 4269 cycles of IUI and 680 women underwent 2345 cycles of ICI with cryopreserved donor sperm. MAIN RESULTS AND THE ROLE OF CHANCE: Baseline characteristics were equally distributed (mean age 34.0 years for the IUI group versus 33.8 years for the ICI group), while in the IUI group, there were more lesbian women than in the ICI group (40.6% for IUI compared with 31.8% for ICI). Cumulative OPRs up to six treatment cycles were 40.5% for IUI and 37.9% for ICI. This corresponds with a hazard rate ratio of 1.02 [95% confidence interval (CI) 0.84-1.23] after controlling for female age and indication. Increasing female age was associated with a lower OPR, in both the IUI and ICI groups with a hazard ratio for ongoing pregnancy of 0.94 per year (95% CI 0.93-0.97). LIMITATIONS, REASONS FOR CAUTION: This study is prone to selection bias due to its retrospective nature. As potential confounders such as parity and duration of subfertility were not registered, the effect of these potential confounders could not be evaluated. WIDER IMPLICATIONS OF THE FINDINGS: In women inseminated with cryopreserved donor sperm in the natural cycle, we found no substantial benefit of IUI over ICI. A randomized controlled trial with economic analysis alongside, it is needed to allow a more definitive conclusion on the cost-effectiveness of insemination with cryopreserved donor sperm. STUDY FUNDING/COMPETING INTERESTS: No funding was used and no conflicts of interest are declared.

Should an intrauterine insemination with donor semen be performed 1 or 2 days after the spontaneous LH rise? A prospective RCT.

STUDY QUESTION: What is the impact on pregnancy rates when intrauterine insemination (IUI) is performed 1 or 2 days after the spontaneous LH rise? SUMMARY ANSWER: IUI 1 day after the spontaneous LH rise results in significantly higher clinical pregnancy rates compared with IUI performed 2 days after the LH rise. WHAT IS KNOWN ALREADY: IUI is scheduled within a limited time interval during which successful conception can be expected. Data about the optimal timing of IUI are based on inseminations following ovarian stimulation. There is no available evidence regarding the correct timing of IUI in a natural menstrual cycle following the occurrence of a spontaneous LH rise. STUDY DESIGN, SIZE, DURATION: A prospective RCT, including patients undergoing IUI with donor sperm in a natural menstrual cycle. IUI cycles (n = 435) were randomized between October 2010 and April 2013, of which 23 were excluded owing to protocol deviation and 412 received the allocated intervention. PARTICIPANTS/MATERIALS, SETTING, METHODS: Serial serum LH concentrations were analysed in samples taken between 07:00 and 09:00 h to detect an LH rise from Day 11 of the cycle onwards. The subjects were randomized to receive insemination either 1 or 2 days after the observed LH rise. In the final analysis, there were 213 cycles in the group receiving IUI 1 day after the LH rise and 199 cycles in the group receiving IUI 2 days after the LH rise. MAIN RESULTS AND THE ROLE OF CHANCE: Significantly higher clinical pregnancy rates per IUI cycle were observed in patients undergoing IUI 1 day after the LH rise when compared with patients undergoing IUI 2 days after the LH rise [19.7 (42/213) versus 11.1% (22/199), P = 0.02]. In view of the timing of sampling for LH, the inseminations were performed at 27 h (±2 h) and 51 h (±2 h) after detection of the LH rise. The risk ratio of achieving a clinical pregnancy if IUI was scheduled 1 day after the LH rise compared with 2 days was 1.78 [95% confidence interval (CI), 1.11-2.88]. This points towards a gain of one additional clinical pregnancy for every 12 cycles performed 1 day instead of 2 days after the LH rise. When analysing the results per patient, including only women who underwent their first treatment cycle of insemination, the outcome was in line with the per cycle analysis, demonstrating an 8% difference in pregnancy rate in favour of the early group (20.5 versus 12.2%), however, this difference was not significant. LIMITATIONS, REASONS FOR CAUTION: Optimal monitoring for the occurrence of the LH rise involves several daily LH measurements, which is not always amenable to everyday clinical practice, however, daily sampling was sufficient to detect a significant difference in pregnancy rate. The strict inclusion of a highly selected population of patients who underwent IUI in a natural cycle may have been a limitation. IUI in a natural menstrual cycle confers lower success rates compared with IUI following ovarian stimulation and is not suitable for patients with ovulatory dysfunction. Furthermore, a similar study in a larger number of women is required to confirm the result in terms of pregnancy rate per patient. WIDER IMPLICATIONS OF THE FINDINGS: This is the first RCT to show that timing of IUI in a natural menstrual cycle is important and that IUI should be performed 1 day after the LH rise, rather than 2 days post-LH rise. Daily monitoring of the rise in LH, as performed in our study, can be adopted to achieve a higher pregnancy rate per IUI cycle. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study. All authors declare to have no conflict of interest with regard to this trial. TRIAL REGISTRATION NUMBER: The trial was registered at clinicaltrials.gov (NCT01622023).

Cumulative delivery rates after ICSI with donor spermatozoa in different age groups.

This retrospective cohort study followed a total of 364 women from their first fresh, donor intracytoplasmic sperm injection (ICSI) cycle through to up to six ICSI cycles. All patients started their treatment between January 2003 and December 2007. Live delivery after 25 weeks of gestation was the main outcome measure. The overall crude cumulative delivery rate (CDR) after six cycles was 66% while the overall expected CDR was 90%. In women aged 38-39 years, the crude and expected CDR after six cycles were 54% and 82%, respectively. In women aged 30-37 years, the crude and expected CDR after six cycles were 66% and 91%, respectively. In women aged 20-29 years the crude and expected CDR after six cycles were 81% and 93%, respectively. No significant difference was found between the CDR of patients who had a primary ICSI treatment (no previous intrauterine insemination) and patients who had previous intrauterine insemination. This study corroborates the impact of age on ICSI with donor spermatozoa.

Factors associated with parents' decisions to tell their adult offspring about the offspring's donor conception.

BACKGROUND: Tensions and anxieties surround secrecy within families in the context of gamete donation and family building. This paper presents the views of parents who had kept their use of donor insemination a secret from their offspring. A sub-set of these parents said that they wished to tell their now-adult offspring, and discussed the questions and issues this secrecy raised to them. METHODS: In-depth interviews were undertaken with heterosexual parents (of 44 families) who had given birth to children conceived via donor insemination between 1983 and 1987. These interviews comprised a follow-up study, with the first interviews being undertaken when the children were aged up to seven. In this paper, qualitative data relating to a sub-set of 12 parents (from seven families) who now wished to tell their offspring are presented. RESULTS: The parents describe the pressures that the secret-keeping had created for them as well as the impact of those pressures. They report on the reasons they now want to share the family building history and the associated fears and anxieties about doing so. The parents all say that they wish they had told their offspring much earlier. In five of the seven families, parents describe how the offspring had raised questions concerning a perceived genetic disconnection between them and their parents. CONCLUSIONS: Keeping the use of donor insemination a secret from offspring created considerable pressure for these parents. Despite the secrecy, offspring can become aware of the genetic disconnection.

Factors affecting fecundity among sperm donors: a multivariate analysis.

UNLABELLED: The study was aimed at identifying the predictors of the male fertility potential among sperm donors. Fifty anonymous donors undergoing 683 intracervical insemination (ICI) cycles between January 2002 and December 2006 were retrospectively evaluated according to semen characteristics in terms of reproduction rate (RR). We used RR as a parameter to determine the fertility potential among sperm donors. The overall RR was 26.79%. There were no significant differences among low, mean and high RR groups with regard to most sperm routine parameters. However, the RR was notably higher in the sperm morphology of ≥18% than in the <18% group (26.2% versus 19.4% respectively; P < 0.01). Both post-thaw total motility and progressive motility were proportional to RR (P < 0.01). Differences in RR were seen when the percentage of propidium iodide-negative spermatozoa was ≥45% (26.2% versus 16.4% respectively; P < 0.01) and DNA fragmentation index (DFI) was <8% (37.5% versus 17.9% respectively; P < 0.01) in post-thaw samples. Using stepwise linear regression analysis, the percentage of normal morphology, post-thaw progressive motility, PI-negative spermatozoa, DFI had the maximum power to predict the donor fecundity in ICIs. CONCLUSION: Both the integrity of plasma membrane and DNA in spermatozoa are crucial factors affecting the fecundity of sperm donors. Therefore, the addition of some of these new tests to routine semen analysis could significantly improve the recruitment of sperm donors and the clinical pregnancy rate of anonymous donors.

[Sperm or oocyte donation: the dynamics of making the decision regarding the method and timing of disclosure of information to the sibling].

A dramatic increase in the number of children born as a result of gamete donation has occurred worldwide over the past decade. Concurrent to the acceleration in the use of gamete donation there has been a growing movement advocating non-anonymity in donor programs and disclosure to the offspring of donor gamete conceptions. The fact that current recommendations concerning gamete donation differ widely among various countries reflects the Lack of consensus around the world, especially in regard to two major issues: donor anonymity and the disclosure decision. In the past, the donors' identity was always kept anonymous, and they were ensured full secrecy. Recently, a 'double track' policy has become increasingly popular. Under this policy, the donor has the choice to enter the program as either an anonymous or an identifiable donor, while the recipient can choose between these two types of donors. This scheme allows the recipients to decide in the future the degree of disclosure that best meets their interest in involving the donor in their lives. The parent's decision regarding disclosure of gamete donation before the child reflects their general philosophy and their individual values regarding the way they manage their Lives, and specifically how they desire to fulfill their role as parents. Study resuLts show that individual counseling appeared to be helpfuL and appreciated by study participants. This is particuLarLy true when delivered without judgment or directive personal opinion. Peer support, often in the form of professionally-led groups, was most highly valued. It seems likely that peer support, not only reduces the sense of isolation and stigma by normalizing the donor experience, but facilitates information acquisition derived from the shared, personal, lived experiences of other parents in the same unique life situation.

Semen donors in Germany: a study exploring motivations and attitudes.

BACKGROUND: Germany is one of the countries where donor insemination (DI) is shrouded in secrecy and where, until recently, donors were assured of anonymity, and clinics were able to destroy documents after 10 years. For many years, preparation seminars for recipients have been conducted. Almost all participants of these seminars intend to disclose the nature of conception to their child, thus representing the beginning of a culture change. This study sought the views of donors regarding their willingness to be identified and therefore meet these expectations. METHODS AND RESULTS: Thirteen of 15 clinics in Germany agreed to participate and of 153 anonymous questionnaires sent, 41% (n = 63, from eight clinics) were returned. Thirty-seven per cent of donors suggested that parents should disclose the nature of the conception to their child, 34% uncertain and 29% opposed. Forty-three percentage were willing to meet offspring, 22% uncertain and 35% opposed. CONCLUSIONS: One-third of the donors supported parental disclosure and just under half of the donors are willing to be identifiable, despite a climate and history of secrecy. This study indicates that there are donors who are agreeable to be part of the move away from secrecy, and this will have implications for professionals involved in providing DI services in Germany.

Cervical insemination versus intra-uterine insemination of donor sperm for subfertility.

BACKGROUND: Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples. Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus. Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates. OBJECTIVES: To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm. SEARCH STRATEGY: The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved. SELECTION CRITERIA: Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available. DATA COLLECTION AND ANALYSIS: Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed. MAIN RESULTS: The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96). AUTHORS' CONCLUSIONS: The findings of this systematic review support the use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.

Donor insemination and infertility: what general urologists need to know.

Therapeutic donor insemination (TDI), also known as artificial insemination by donor, is one of the oldest forms of male infertility treatment. With the advent of assisted reproductive technologies and in vitro fertilization techniques over the past few decades, the use of TDI in male infertility treatment has decreased dramatically. Knowledge of its use, indications, efficacy, and related psychosocial issues has also declined among urologists treating male infertility. Despite the change in popularity of the procedure, though, TDI remains an appropriate therapeutic option for certain cases of male infertility, particularly in patients who have failed multiple cycles of in vitro fertilization/intracytoplasmic sperm injection or in men with no available sperm even after attempted microdissection testicular sperm extraction. Further consideration and research should be focused on the potential uses and indications for TDI.

Practice experiences of running UK DonorLink, a voluntary information exchange register for adults related through donor conception.

Previous practices of withholding information from those conceived through donor conception are changing. However, little is known about the service needs of those affected. In response to this, the UK Government-funded pilot voluntary information exchange and contact register, UK DonorLink, was launched in 2004, covering conceptions prior to August 1991. It is the only register worldwide that relies primarily on DNA testing to establish genetic connectedness in the absence of written records. Approximately 150 adults came forward to register in the first three years of operation, drawn from all interested parties. Matches between half-siblings have been made, but none yet between donor and offspring. Employing staff with expertise in post-adoption work has proved effective, as long as additional training and support specific to donor issues is provided. The infrastructure required to promote and deliver the service reflects the complex mix of skills and tasks required, and confirms that a service provided through independent counsellors alone would be inappropriate. Having a geographically and socially widespread potential registrant group, together with a limited budget, has limited the effectiveness of advertising and promotion campaigns. Ethical and emotional complexities arising through the direct service are highlighted, including those presented by DNA use.

Good efficiency of intrauterine insemination programme for serodiscordant couples with HIV-1 infected male partner: a retrospective comparative study.

OBJECTIVE: Assisted reproduction techniques can minimize the risk of HIV female contamination when the male partner is HIV-infected. The aim of this study was to investigate the efficiency of sperm washing and intrauterine insemination (IUI) in these couples. STUDY DESIGN: Retrospective comparative study. Eighty-four HIV-1 serodicordant couples underwent 294 IUI. The control group was composed of 90 couples (320 IUI cycles) with donor sperm. Spermatozoa from HIV-1 infected male partner were prepared and tested for HIV-1 according to sperm washing method. Spermatozoa from HIV-1 and donor male were frozen before IUI. IUI were performed after ovarian stimulation. Main outcomes measures were pregnancy rate per cycle and baby take-home rate per couples. RESULTS: Although the pregnancy rate and baby take-home rate were higher in IUI with sperm washing than in IUI using donor sperm (18.0 versus 14.7 and 52.4 versus 41.1, respectively), the differences were not statistically significant. In serodiscordant couples, blood estradiol levels under ovarian stimulation and total motile sperm inseminated were a determining factor in achieving pregnancy. No female HIV-1 contamination occurred. CONCLUSION: This study demonstrates that sperm washing and IUI are highly effective in enabling serodiscordant couples with an HIV-1 infected male partner to have a child.

Intrauterine insemination results in couples requiring extended semen transport time.

PURPOSE: The purpose of the present study is to compare intrauterine insemination (IUI) pregnancy rates (PR) as a function of diagnosis and ovulation protocol utilizing an extended semen transport time. This allowed clients to conveniently collect IUI specimens in the comfort and privacy of their home. A single IUI per treatment cycle was performed. BASIC PROCEDURES: Three-hundred-ten consecutive infertilty couples having unexplained, male factor, ovulatory dysfunction, endometriosis, tubal factor or combined diagnostic factors receiving a total of 584 cycles of IUI were included. Ovulation protocols included LH surge, clomiphene citrate (CC)-hCG, CC-gonadotropins(Gn)-hCG, Gn-hCG or leuprolide acetate (L)-Gn-hCG followed 36-42 hours by a single IUI. Pregnancy rates per cycle (fecundity) and per couple (fertility) as a function of diagnosis, ovulation protocol and cycle number were evaluated. In each cycle the couples processed the specimen by adding sperm washing medium at room temperature to the specimen 30 min following collection and allowed it to incubate for two hours prior to IUI during transport. MAIN FINDINGS: Overall, fecundity was 11.8% (69/584) and fertility was 22.3% (69/310); respectively by diagnosis was: unexplained 22.6%, 38.8%; male factor 18.8%, 42.9%; ovulatory dysfunction 12.4, 22.6%; endometriosis 5.3%, 11.1%; tubal factor 7.6%,13.3%; and combined factors 9.7%, 20.0%. Unexplained vs endometriosis (P < 0.0001, P < 0.005), tubal factor (fecundity P < 0.008) and ovulatory dysfunction (fecundity P < 0.027) was statistically different. Male factor vs endometriosis (P < 0.011, P < 0.036) was significantly different. Ovulatory dysfunction vs endometriosis was significantly different (fecundity P < 0.027). Pregnancies by ovulation protocol: LH surge 4.5%,10.5%; CC-hCG 9.4%,14.9%; CC-Gn-hCG 13.7%, 23.7%; Gn-hCG 17.5%, 45.3%; L-Gn-hCG 3.5%, 6.7%. For Gn-hCG vs L-Gn-hCG (P < 0.009, P < 0.030) and LH surge (fecundity P < 0.033). CC-Gn-hCG vs CC-hCG (fertility P < 0.050) and L-Gn-hCG (P < 0.033, P < 0.034). Gn-hCG vs CC-hCG (fecundity P < 0.043). CONCLUSIONS: We conclude that IUI is effective when utilizing an extended transport time allowing most couples to collect the specimen at home and is most effective when utilizing Gn-hCG therapy. Based on our analysis, endometriosis, tubal factor and combined diagnostic categories should proceed earlier to higher level assisted reproductive technologies.

[Optimization of artificial inseminations with donor semen: a four-year experience]. / Optimisation des résultats d'inséminations intra-utérines uniques avec sperme de donneur: bilan de quatre ans d'activité.

OBJECTIVE: Our aim was to analyse the results of a donor insemination program using ovarian stimulation, swim-up sperm preparation and intrauterine insemination proposed to women with a maximum age of 39. Incidence of several clinical and biological parameters on success rates was investigated. PATIENTS AND METHODS: Retrospective analysis of the results of 249 cycles performed in 106 couples during a four-year period is reported. RESULTS: Overall pregnancy rate of 28.1% and delivery rate of 22% per cycle were achieved, with a multiple pregnancy rate of 11.4%. Most of the pregnancies (84%) were obtained before the fourth insemination. Among the different parameters studied the total number of motile sperm inseminated was found to be the most important factor for success rate: pregnancy rate per cycle reached 40.4% if more than 1.5 million progressive sperm were inseminated vs. 24.7% if they were less than 1.5 million (P<0.05). DISCUSSION AND CONCLUSION: In precise conditions, outcome of inseminations with donor semen can reach satisfying pregnancy rates, being a valuable help for couples suffering of long-time infertility.