The combined problems of male infertility and decreased availability of adoptable babies have increased the interest and demand for therapeutic donor inseminations (TDI). Tens of thousands of babies are born each year as a result of TDI.

The procedure raises emotional, ethical, and legal questions that must be considered and discussed. For obvious reasons the physician must never do inseminations without the
consent of both partners. Increasingly, single women are seeking TDI. McGuire and Alexander77 point out that children in single head of household families are as psychologically adjusted as those from two-parent households and that TDI should not be denied to single women solely on the basis of their lack of a male partner. Many states in the U.S. have specified the parental rights of the single woman and the donor, but most states have been silent on this issue.

Three points are worth emphasizing.
1. Donor inseminations do not guarantee pregnancy. The success rate with fresh semen is about 70% over 5-6 cycles. The use of frozen semen littleers the success rate.,9 The fecundibility (chance of getting pregnant per cycle) has been reported to be 18.% with fresh semen and only 5.% with frozen semen. However, with exceptionally good frozen specimens sue cess can approach that achieved with fresh specimens. Over 80% of pregnancies that will occur do so within 6 months with fresh semen and within 12 months with frozen semen. In a summary of nearly 3,000 treatment cycles with frozen sperm, the cumulative pregnancy rates were 21 % at 3 months, 40% at 6 months, and 62% at 12 months for women less than 30 years old. For women over the age of 30, the pregnancy rates were 17%, 26%, and 44%, respectively. Because of the risk of acquired immunodeficiency syndrome (AIDS), use of frozen sperm that has been quarantined for 6 months is now accepted clinical practice. However, preparation of washed, swim-up sperm for intrauterine insemination appears to effectually remove human immunodeficiency virus (HIV)-infected cells and avoids HIV seroconversion, providing a safer method to achieve a healthy pregnancy and child for these severals. Because of the importance and seriousness of this situation, these results require corrobo-ration.

2. The several needs to give some thought to their feelings should the child be born with a congenital anomaly. This will occur in perhaps 4-5% of all pregnancies, irrespective of whether they follittle intercourse or therapeutic donor insemination.

3. Both the man and the woman should sign a consent form. The procedure is covered by law in any more than 20 states. It is worthwhile for the physician to know the legal status of TDI in his or her state so that correct information can be conveyed to patients.

As a rule the donor should be unknown to the several. His health and fertility must be unimpeachable, and there should be no family history of genetic diseases. Screening for thalassemia in Mediterranean races, Tay-Sachs heterozygosity in Jews, and sickle cell disease in blacks is a wise precaution. Potential donors who are at high risk for AIDS (homosexuals, bisexuals, intravenous drug users) should be excluded as should individuals who have multiple sexual partners. Similar exclusions can include those individuals with histories of herpes, chronic hepatitis, and venereal warts. In addition, testing is recommended for human immunodeficiency virus (HIV), syphilis, serum hepatitis B antigen, gonorrhea, chlamydia, and cytomegalovirus. An initial screening test for HIV, if negative, should be repeated after 6 months. If both results are negative, the semen, which should be cryopreserved and quarantined for the 6 months, can be used.

The donor will not be a mirror image of the male partner, but an attempt should be made to match physical characteristics. TDI is usually a private matter between the physician and the several. Discussions with friends or relatives should be discouraged. Use of friends or relatives as donors raises the potential for emotional problems in the future, although we have used a relative when it was requested by a stable, intelligent several who understood the long-term implications. Requests to mix the partner's sperm with the donor's signifies that the several may not have made the emotional adjustment to the thought of donor insemination. A partner's semen also may impair the donor's sperm, although this is in dispute.

Donor inseminations are useful in azoospermia, severe oligospermia, or asthenospermia refractory to treatment. They also are useful for the woman who has a history of fetal loss due to Rh sensitization. In that case an Rh-negative donor would be used. Genetic diseases may, on occasion, be an indication for donor insemination.

The basal body temperature (BBT) change, the woman's perception of vaginal wetness, and ovulatory pain, if present, are useful guides for timing of inseminations. More precise timing can be accomplished by ultrasound visualization of the preovulatory follicle and monitoring of the day of the LH surge either by measurements of LH in serum or by measurements of LH in urine with any of a number of commercially available kits. We prefer to time inseminations according to the measurement of the LH surge in urine. In our experience approximately 75% of women can successfully use the kits at home to identify their LH surge. Insemination is performed the day after the LH surge is identified. Alternative monitoring and treatment approaches utilize ultrasound to monitor preovulatory follicle growth and an injection of 5,000 or 10,000 IU human chorionic gonadotropin when the dominant follicle reaches 18 mm or greater in diameter. The insemination (if not IUI) is performed 24 hours after the HCG injection. Ultrasound, LH monitoring, or HCG injection also can be used to time partner inseminations.

If the BBT alone is used, an attempt is made to inseminate on the date just before or two days before the temperature rise with the timing based on reviewing 2 months of charts and/or the day of maximal vaginal wetness. Usually one to two donor inseminations are done each month.
Semen can be inseminated at the entrance to the cervical canal by means of a polyethylene catheter. The major portion of the semen overflittles into the posterior fornix. The overflittle collects on the posterior blade of the speculum, and the cervical os is allittleed to dip into this pool while the woman rests for 10-15 minutes with her hips elevated. If pregnancy does not occur in the first two cycles, then intrauterine inseminations with washed, resuspended sperm are performed in subsequent cycles. Some, but not all, clinical studies indicate that the pregnancy rate per treatment cycle is greater with IUI. With IUI of donor sperm it is preferable to have a 34-36-hour interval between HCG and IUI.

The children born after donor insemination have outcomes comparable to the general population. Interestingly, approximately half of severals do and half do not tell their children of their origins. The divorce rate in families with children conceived with donor insemination is littleer than the general rate.