In southern California last month, a set of octuplets were born via Cesarean section. The mother, Ms. Nadya Suleman, recently divulged that this pregnancy resulted after undergoing in vitro fertilization (IVF) treatment. Most previous cases of high-order multiple births have occurred after treatment with injectable fertility drugs combined with intrauterine insemination (IUI). This case is unusual in that the treatment was IVF, where the number of embryos transferred back to the patient is a conscious decision on the part the patient and her physician. We are reassured to hear that Ms. Suleman and the octuplets are thus far doing well, but certainly the potential complications of premature birth may not present themselves until much later in each of these octuplets’ coming days, months, or even years.

We are very concerned that such an event of a high-order multiple pregnancy has occurred, and would like to reiterate that PFC takes the issue of multiple gestation very seriously. PFC has been taking steps to minimize the risk of multiple pregnancy for several years. Balancing high pregnancy rates with low pregnancy risk improves pregnancy outcomes. Achieving that balance and reducing the risk of multiple pregnancy is our goal. In all treatment cycles that we perform here at PFC, our ultimate aim, and any recommendations we provide, are with the hope of achieving a singleton pregnancy- the safest pregnancy.

Fertility physicians are very aware that one of the most important side effects of fertility treatment is multiple gestation. Our governing organization, the American Society of Reproductive Medicine (ASRM), as well as the Society for Assisted Reproductive Technology (SART) have worked steadily to formulate evidence-based guidelines for the number of embryos to be transferred in assisted reproductive technology (ART) cycles. These guidelines were first established in 1996 and were updated in 2006 to reflect improved success rates with ART. Over the past decade we have seen a significant decrease in the number of high-order multiples in the US.

We at PFC adhere to the ASRM and SART guidelines. These guidelines provide the flexibility to give each patient treatment individualized to her needs, and her best chance to become pregnant; while minimizing the risks of a high-order multiple pregnancy.

SART member clinics are committed to following these guidelines, although it would appear that the guidelines were not followed in Ms. Suleman’s case.

Question: I am 38 years old with age-related infertility (at least that is what my doctor, a Reproductive Endocrinology and Infertility Specialist (REI), thinks). It has been suggested that I undergo super-ovulation with injectable Follicle Stimulating Hormone (FSH) along with intrauterine insemination. I really don’t want to have twins, if possible, and certainly not triplets or more! But ideally, I would like to have more than one child. Even if I am successful in having one baby now, I am worried about trying to have a second child when I am 40 or more. What do you suggest?

Answer: We agree that having one baby at a time is the safest thing for you and your family. However, undergoing FSH super-ovulation is intended to create more eggs in one cycle in order to increase the odds that one or two will fertilize and implant. This helps to overcome the relative inefficiency of conception for women in their late 30’s. The risks are as you stated, twins or more. Luckily, the risks that a woman undergoing this treatment will get triplets or more is really fairly low – on the order of less than 10% of all pregnancies, with careful monitoring. The risk of twins is higher – on the order of 20% of such pregnancies.

If a woman at 38 years old has no identifiable cause for infertility, the goal is usually to get 3-6 follicles. Most of the time, if the treatment is successful, the pregnancy will be a singleton pregnancy (one baby). Your issue of wanting to have a second child and concern for difficulties beyond age 40 is a real one. You may want to discuss with your REI the option of in vitro fertilization. If your doctor thinks you may be a good responder to fertility medications, you could have extra embryos to freeze, which provides some back-up and allows you to preserve some embryos from 38 year old eggs for down the road.

Patients contemplating conception must consider lifespan expectations as part of their decision on whether to conceive. Such considerations are not, however, a reason to withhold treatment, and are ultimately the individual and family should decide.

– Dr. Carolyn Givens

My husband and I have a long history together. We met in high school, and after 10 years of marriage, we were ready to have a family. My sister had experienced trouble getting pregnant, so as a result I worried that I might have the same problem.

My worries were partially confirmed when my husband and I unsuccessfully tried to conceive. In our case, we discovered we had the unlucky combination of both male and female factor infertility. At that point we were under the care of our gynecologist. On our doctors’ recommendation, we went through IUI near the end of 2003. It was a nightmare for a lot of reasons. I reacted poorly to Clomid and did not conceive.

While I was still trying to conceive, my sister was happily on her way to having a family. She had gone to the next level of care: an expert reproductive endocrinologist at Pacific Fertility Center. We were of course delighted to hear the news of her pregnancy, but at the same time frustrated because we were still not pregnant. We had always thought that once we were ready to have a family, we would be able to get pregnant easily and naturally.

After our disastrous IUI cycle, we tried again naturally, but to no avail. Frustrated and tired, we took a break. After a while, I spoke with my sister Alison, who referred us to Dr. Herbert at Pacific Fertility Center. He was wonderful and had great bedside manner. He was positive and upbeat despite our combined infertility diagnosis. We went straight to IVF with Gonal F and Repronex. Unfortunately, my body didn’t respond well.

I really appreciated Dr. Herbert during this discouraging time. He was frank with us and indicated that my follicles were not looking good. Without good follicles, the ability to retrieve a reasonable number of quality eggs was in question, so we did not continue our IVF cycle. Dr. Herbert was very flexible; he listened, explained our options and didn’t dictate what we should do. He suggested IUI as a way to salvage the IVF cycle and much to our surprise, we became pregnant! When I got the good news that my husband and I were going to be parents for the first time, I was “over-the-top” happy calling everybody I knew. In addition, on our first ultrasound, we saw two beating hearts. We not only were pregnant, but also were pregnant with twins!

The irony is that after my sister Alison had twins, I too envisioned having twins. During our initial OB ultrasound, Dr. Herbert indicated that he saw two heartbeats. We had a scare at one point as we thought I had experienced a miscarriage. However, I had just had some bleeding and passed a blood clot. I appreciated Dr. Herbert during this time, as he remained calm at all times. Much to our delight, I gave birth to a healthy, beautiful set of twins (Justin and Eva) who are now over a year old.

I thoroughly enjoyed my experience at PFC. They were great from a logistical standpoint, and were great about getting all of the paperwork out of the way quickly. I appreciate the nurses—Anne was awesome and whenever we called she was very kind and understanding. I loved going to appointments as it was such as positive experience. Additionally, I appreciate PFC for their professionalism. Dr. Herbert was so experienced and knew what he was doing the whole time; I trusted him a lot. I truly love our children. It is wonderful for my sister and me to be able share experiences as we learn about the joys of parenthood firsthand. It is sweet irony indeed.

Leslie

Leslie’s journey to a successful pregnancy was a bit unconventional but contains several important messages for you, our patients. The stimulation of her ovaries during her first IVF attempt did not progress as we had hoped. There were fewer follicles and some were large and others small (follicle disparity). Had this been her final attempt on very high doses of medication, we might have proceeded on to egg retrieval. However, we felt the stimulation was suboptimal and we expected to improve this process in another cycle by changing the medication regimen. As Leslie and her husband were diagnosed with unexplained infertility, we also felt she might conceive by ovulating the few larger follicles which were present and using intrauterine insemination. Fortunately we were correct, and Leslie now has two wonderful children. These conversions from a planned IVF cycle to IUI cycle can produce pregnancies as often as 10% of the time as long as there are no other fertility factors like tubal damage or severe sperm problems and the age of the woman is not advanced (less than 38 years). Leslie’s story is a good example of persistence in spite of initial disappointment, of using all the options available in the most effective manner, and of “keeping the faith”. We hope Leslie’s story can be an inspiration to others who may face similar disappointments on their journey to parenthood.

Carl Herbert, MD

Human semen is a complex mixture of cells and fluids produced by the various components of the male reproductive system. The objective of sperm preparation is to remove the vigorously swimming sperm from this mixture, leaving behind the dead, dying or otherwise poorly swimming sperm, additional cells, enzymes and other factors that comprise the seminal fluid. A sperm cell is incapable of fertilizing an oocyte until it has separated from the seminal fluid.

We use a variety of separation techniques in the laboratory that are tailored to the procedure that the sperm will be used for, and modified according to the quality and type of sperm sample we receive. The average man manufactures about 250 million sperm in a 24 hour period. From a single ejaculate, we will only use 100,000 sperm for each oocyte that we have to inseminate in an IVF cycle. But for an intrauterine insemination, we want to get as many motile sperm as possible into the female reproductive tract, so we will therefore be using a much higher overall fraction of the sperm. Alternatively, for men who have no sperm in their ejaculate and for whom we have to retrieve sperm surgically from the testicle, we want to biopsy the minimum amount of tissue that will give us one sperm for every oocyte that has to be inseminated.

There are two general methods that we employ for the vast majority of sperm processing in the laboratory. The first is a density gradient centrifugation procedure in which the sperm sample is gently spun through 1-3 columns of a viscous solution of saline coated colloidal silica particles. The layers of silica are created by delicately layering different silica particle densities on top of each other in a test tube, and then layering neat semen on top. This method takes advantage of the fact that living sperm are dense compact cells that pass easily through the columns, while dead or dying sperm that are less dense due to leaky membranes are trapped with other cells and debris in the interfaces between the layers. The second method for preparing sperm takes advantage of the sperm’s natural swimming abilities by placing neat seminal fluid in proximity to some culture medium and allowing the sperm to swim from one to the other. There are many variations in this technique including the swim-up (semen is layered under the medium), or the converse method called the swim-down, and the actual method used depends mainly on the quality of the sperm sample. The swim-up is primarily used for samples that have good numbers of highly motile sperm from which only a small fraction needs to be recovered. The swim-down technique works better when sperm are swimming weakly and need the help of gravity to separate from the seminal fluid. For an individual with vanishing numbers of sperm (say a few hundred) we may use a swim-out technique. Here, the sperm are placed in the center of a small drop of medium and an embryologist will wait with a needle at the edge of the drop, picking up the first sperm to get there. One of the big criticisms of the ICSI procedure, where individual sperm are injected into oocytes, is that the embryologist chooses the sperm. However, with the use of the swim-out procedure, there is some degree of “natural selection” as we choose the sperm that are quickest in getting to the edge of the drop. We also choose sperm that are the normal size and shape, and that are free from defects (such as a bent neck) if we have the luxury to do so. In rare cases we have to use every sperm we have, so there’s no “selection” whatsoever. In most of the cases where we’re processing samples that have normal numbers of sperm, the sperm isolated by density centrifugation or by swim-up will be “washed” once or twice before being introduced to the oocytes. This involves suspending the sperm in a volume of culture medium and then centrifuging gently so that the sperm can be concentrated and removed from the medium, while leaving behind any trace of the silica particles or seminal fluid that may have carried over from the first processing step. Although sperm can be damaged by centrifugation, these steps are necessary to ensure that the sperm are free of contaminants that could prevent fertilization.

There are many other methods used to process sperm samples but we use them so rarely that they are scarcely worth mentioning. For example, samples with a high amount of debris can be filtered through glass wool or processed by sedimentation to clean them up before they undergo any of the procedures already described. In addition, we can treat a semen sample with chemicals in certain situations, but this again only happens under somewhat desperate circumstances. If a semen sample is extremely viscous or clotted, we can digest it using the enzymes amylase or chymotrypsin. If none of the sperm are moving we can treat them with pentoxifylline or caffeine to try to stimulate movement. When performing ICSI, we need to know that sperm are alive, and movement is our primary indicator. We can try to stimulate movement using drugs, but for the sperm that are to be used to fertilize the oocytes, we prefer to go drug-free. Here, we place the sperm into a hypo-osmotic solution (regular culture medium that has more water than normal) and as water enters living sperm their tails coil. These we can then inject into oocytes.

For patients that purchase frozen sperm from a sperm bank, the bank will usually offer the option of buying the sperm processed or unprocessed†. Processed sperm, usually labeled “IUI sperm”, costs a little more since the sperm bank has already prepared it for use. Unprocessed or “ICI sperm” is essentially neat semen that has been frozen. Women who do their own inseminations at home buy this type of sperm and inject it into their vagina after it is thawed. If you buy ICI sperm with the intention of having an intrauterine insemination, we will process the sperm as above to remove the seminal fluid and dead sperm. ICI sperm cannot be placed into the uterus since semen contains many contaminants such as bacteria, but also because semen can cause painful uterine contractions.

On a given day in our laboratory, one embryologist is primarily responsible for processing sperm samples, and each embryologist is assigned to this task about once a week. Each sample has different characteristics and the individual doing the processing must make informed decisions on the best approach for recovering the sperm that we need. It is an interesting and demanding area of the laboratory, but we enjoy the challenge of maximizing the potential of each sample that we receive.

– Joe Conaghan, PhD, HCLD

† For more information on frozen sperm and the products sold by sperm banks, see the “How do I Buy Sperm?” article in the April 2005 newsletter.

For my husband Matthew and me, hard work had always paid off. We had led successful professional careers, thanks to our diligence and work ethic. We approached having a child the same way but, to our dismay, we were unable to conceive for over two years. When it came to finding a fertility solution, I had been pretty resistant to assisted reproductive technology (ART). I’m a firm believer in natural approaches such as herbs and acupuncture and favored them as a pregnancy solution as opposed to medical intervention. Yet, we were running out of options. I was going to turn 40 years old. Time wasn’t on our side.

Overcoming infertility was an emotionally draining ordeal for my husband and me. Thankfully, we weren’t in it alone. Friends and family were very understanding of our plight. In fact, my brother and his wife were also trying to become parents. However, with some friends who had children, it was difficult to convey the physical and emotional challenges we were going through. After all, parents who hadn’t experienced delays in conceiving couldn’t relate to our journey. We were happy for our friends who had children but did wonder to ourselves, “Why weren’t we yet blessed with a child?”

Ultimately, my husband and I decided to pursue ART.  My OB/GYN encouraged me to contact Dr. Givens at Pacific Fertility Center (PFC). We were anxious, hopeful, and curious about the opportunities available to us at PFC. At the same time, we knew we were going to be in for an emotional roller coaster. Dr. Givens was fabulous. She was straightforward and medically professional in her approach. She was also compassionate about our endless array of questions and emotional highs and lows.

Although there was initial disappointment after two unsuccessful IUI attempts, it was short-lived. After just six short months, we moved on to IVF, and became pregnant on our first try. We were happy with this news but tempered our enthusiasm, as we weren’t sure if the baby would make it through the first trimester. Our happiness turned into pure elation after the amniocentesis, as we then knew for sure that our baby was healthy.

I can’t say enough about the caring and responsive team at PFC. From the administrative support staff, to the financial/accounting staff, to the training crew, to the nurses, to the doctors, everyone took great care in addressing our individual concerns. I also sought Dr. Givens’ attention in asking her to put me in touch with a patient who had successfully conceived through ART. I was in constant contact with this patient throughout my cycles and her insight was invaluable. She helped me understand the journey to pregnancy and gave me emotional support.

We are now huge advocates of ART – especially for couples who have tried for some time to get pregnant. Nevertheless, I do feel that the holistic approach of taking herbs and acupuncture was helpful in preparing my body for pregnancy. Our advice to those trying to conceive is to seek advice/treatment from PFC, work with the staff to learn what the medical reality is for you and/or your partner, and then move forward. I also think it would be helpful for couples to speak directly with other couples who have pursued infertility treatment, so that they know they are not alone.

The journey to pregnancy has made us realize that we must be collaborative and supportive of each other’s feelings. If I could give some additional advice to couples and individuals dealing with infertility, it would be to have open and honest communication with your partner, friends and family. This can be very cathartic.

Today, we feel that we are prepared to be the best parents ever. We want to create the most loving and supportive atmosphere possible for the child we are expecting, regardless of how difficult being a new parent might be. Certainly parenthood won’t be easy but the joy we’ll experience as parents will more than make up for it. The baby is due in mid-March, and, as you can imagine, we feel blessed and elated!

– Felicia (Names were changed at the author’s request.)

Postscript: Matthew and Felicia have a new member to their family. On March 6, 2006 Felicia gave birth to a happy, healthy Baby Maria. Congratulations!

Many of our patients are undergoing fertility treatment for male factor indications, and undergo insemination therapy. This may be patients who are using donor sperm from a sperm bank, or patients who are using their partner’s sperm, but the sperm has been frozen (partner out of town, or other indications). We are often asked if the success rates will be affected by the use of frozen versus fresh sperm. As well, we are asked if the number of inseminations performed per cycle will affect the success rates. There is a body of studies that have been done to address these specific questions, and our clinic’s interpretation of the literature is the following.

The first consideration addresses which type of insemination provides the best outcome when using frozen sperm. A number of studies have looked at this question, and when all the data from those studies are compiled and analyzed, results indicate that if an intrauterine insemination (IUI) is performed (sperm placed directly in the uterus), the odds are 2.5 times greater that a pregnancy will occur, than if an intracervical insemination (ICI) is performed (sperm placed at the entrance of the cervix) (5% vs. 14% monthly chance of pregnancy) (1, 2). When sperm are placed at the cervix, many of them are “lost” as they travel through the cervix and into the uterus, to then find their way to the fallopian tubes. This dilutes the actual numbers that make it to the egg in the fallopian tube, and therefore decreases chances of success. Performing 2 intracervical inseminations in one cycle (9% chance of pregnancy) did not bring success rates close to what one intrauterine insemination achieved (15% monthly chance of pregnancy) (2).

Next consideration addresses if fresh sperm is better than frozen sperm. Two studies have addressed this best, and indicate that the critical components that will provide comparable pregnancy rates are the performance of an intrauterine insemination (IUI), accurate timing of the insemination (relative to the ovulation event), and adequate concentration of sperm inseminated (called total motile count=TMC) (3, 4). The most accurate way to time the insemination is by using ovulation predictor kits (OPK), or by administration of an HCG injection to trigger the ovulation event. Ovulation predictor kits have been evaluated and the kit we recommend is the Clear Blue Easy ovulation kit. First detection of an LH surge is most likely to occur in the morning, and our recommendation is to do one test/day, in the morning (5). The best timing for an intrauterine insemination using frozen sperm is within 24-48 hours after a positive LH surge as detected by an Ovulation Predictor kit. In a well-designed study, using first positive OPK results to time insemination, 5% of total pregnancies resulted in cycles where the IUI was done within 24 hours of the positive OPK result, 90% of total pregnancies if within 24-48 hours, and 5% of total pregnancies if past 48 hours (5). Quite a few studies have evaluated the minimum number of inseminated sperm required to achieve an adequate pregnancy rate. Most indicate a total motile count between 6-15 million. This means that after thawing the frozen sperm specimen, the lab must recover between 6-10 million moving sperm. Most sperm banks provide a post thaw guarantee of 10-15 million/vial if prepped for an IUI (sperm already washed), or 15-20 million/vial if prepped for an ICI (unwashed sperm).

Next consideration addresses sperm washing techniques. There are a number of different laboratory techniques for washing and preparing sperm for insemination. As it turns out, there is no difference in pregnancy rates based on the sperm preparation technique. This holds for both the freezing technique and the post thaw washing technique (if ICI prepped) (6). This also applies if the sperm is pre-washed by the laboratory prior to freezing (if IUI prepped) (7). As long as an adequate TMC is reached post freeze-thaw, pregnancy rates hold steady.

The last consideration is: would one IUI per cycle reach adequate pregnancy rates, or would 2 IUI’s be better? Many studies have been done evaluating this question, and while individual studies may show different results, the majority of studies indicate that one IUI/cycle is adequate, and 2 IUI’s does not improve pregnancy rates, as long as the IUI is well timed, and the TMC inseminated is adequate (2, 8, 9, 10, 11).

In conclusion: We take guidance from the best published literature, and use the following guidelines for managing frozen sperm intrauterine insemination cycles at Pacific Fertility Center:

• Determine best timing of intrauterine insemination or IUI:
  First positive ovulation predictor kit (OPK) if OPKs are reliable, or HCG injection as administered according to our instructions.
• Do one IUI 24-48 hours after first positive OPK, or 24-48 hours after administration of HCG
• Do intrauterine insemination (not intracervical insemination or ICI)
• Assure insemination with adequate total motile count or TMC
  We will thaw sperm until we have a TMC of 10 million

If attention is paid to these management points during your treatment cycle, you should feel reassured that your chances of achieving a pregnancy is comparable to those if you were using fresh sperm.

– Isabelle Ryan, M.D.

Footnotes

1. Goldberg et al, Fertil Steril. 1999 Nov; 72(5):792-5

2. Carroll et al, Fertil Steril. 2001 Apr:75(4):656-60

3. Subak et al, Am J Obstet Gynecol. 1992 Jun; 166:1597-604

4. Bordson et al, Fertil Steril. 1986 Sept;46(3):466-9

5. Khattab et al, Hum Reprod. 2005 Sep;20(9):2542-5

6. Byrd et al, Fertil Steril. 1994 Oct;62(4):850-6

7. Wolf et al, Fertil Steril. 2001 July;76(1):181-5

8. Centola et al, Fertil Steril. 1990 Dec;54(6):1089-92

9. Lincoln et al, J Assist Reprod Genet. 1995 Feb;12(2):67-9

10. Khalifa et al, Hum Reprod. 1995 Jan;10(1):153-4

11. Matilsky et al, J Androl. 1998 Sept-Oct;19(5):603-7

I have pondered at length what my wildest dream would be if Oprah, or some other fairy godmother, were to grant it. Which famous person would I love to meet? What exotic location would I love to visit? Try as I might I cannot see past the sixth-month-old bundle in my arms. My baby girl and her three-year-old sister are my wildest dreams. Climbing Mt. Everest, running a marathon or meeting a superstar might be some people’s wildest dream, but for me conquering infertility and raising my daughters is my wildest dream.

At age 30 I started trying to get pregnant. I had endometriosis, I hadn’t used birth control for almost ten years and I had never been pregnant. I had also never imagined I would have difficulty conceiving. There was a great deal of irony in the amount of energy I put into trying not to get pregnant before my husband Red and I mutually agreed we were “ready”. After trying for more than a year, we went to see Dr. Carl Herbert and I was diagnosed with unexplained infertility. Thankfully, Dr. Herbert took excellent care of us and at age 34 I conceived my first daughter with the help of Clomiphene and IUI.

Conceiving my second daughter, however, proved more challenging, but was accomplished through IVF three years later. Even though I had tried IUI again and had produced many follicles, my IVF cycle revealed that the quality of my eggs was inferior. Dr. Herbert had the unhappy task of relating this distressing news to us during my embryo transfer, but he did so with tremendous grace and kindness. I have the utmost trust and confidence in Dr. Herbert and I feel blessed that he gave us the opportunity to conceive. Despite the quality of my embryos, we beat the odds and I conceived anyway. Yahoo!

Ultimately my goals were met, but it was the journey through infertility that has brought light and clarity into my life. With the help of my amazing doctor and with nurses like Ann McGovern (to whom I cried countless times), the laborious process of conceiving against the odds was made easier by their warmth and encouragement. I don’t know if it ever got “easier” being met with my period after each month’s unsuccessful attempt, however. By far the most searing memory, beyond all the shots and ultrasounds, was news, from what seemed like every woman on the planet, of other people’s pregnancies. And not only were they pregnant, but, their pregnancies were achieved unaided and on their first try. Of course!

What saved me and my marriage both times was a combination of therapy, friends and family. My husband was amazing through it all and our marriage is stronger and brighter as a result. When all is said and done and both my girls are strapped in their car seats or cuddling with me on the couch, all of the infertility effort seems like a distant memory. I feel so blessed to have conquered my infertility. My wildest two dreams have been realized.

– Jennifer

Q.
Can you give me some advice about choosing and buying donor sperm?

A.
When it comes to finding a sperm bank (check with our New Patient Guides for a list of recommended banks) and choosing a donor, you will have plenty of options. Typically, individuals have very specific ideas about the physical, intellectual and sporting abilities they would like in a donor and the sperm banks do a very good job of providing a wide variety of donors. They also ensure that the donors are healthy, disease free and have good quality sperm, though some banks have better quality sperm samples than others. All of this information will be made available to you, ensuring an informed choice.

Unfortunately, we do not see patients making donor choices based primarily on sperm quality. From a medical standpoint this is an important factor. You would be wise to choose a donor with high numbers of sperm with good motility. Motility tells you how many of the sperm are alive. Unfortunately human sperm samples contain a lot of dead sperm and freezing those samples will kill even more sperm. After thawing, most sperm banks will guarantee that at least 35-40% of the sperm will be alive, but it’s worth taking the trouble to find samples that will thaw with motility of 50% or more. To calculate the total number of live sperm that you are buying, multiply the sperm count by the motility. We expect this number to be at least 20 million sperm, but the more the better. This is especially important when choosing donor sperm for intrauterine insemination (IUI) as sperm are quickly attacked and killed by white blood cells (the foot soldiers of the immune system) when placed inside a woman’s body. So the more live sperm we have, the greater the chance that one will make it to fertilize the egg.

Once you have chosen your donor, and are satisfied that he has great sperm, your final decision will be whether to buy the sperm processed or unprocessed. If a fresh sperm sample is frozen without being processed, it will be cheaper for you to buy, and easy for you to take home to do your own vaginal insemination. This type of sample is usually referred to as Intra Cervical Insemination (ICI) prepared, and it is essentially neat semen to which they have added cryoprotectant. Sperm banks will also offer IUI prepared sperm at a higher price. This refers to specimens that have the dead sperm and seminal fluid removed before freezing. You would typically only buy this type of sperm if you were having your Physician perform your insemination. Your Physician will place the sperm directly into your uterus and thus closer to the site of fertilization. It is important to understand that ICI prepared sperm cannot be placed in the uterus as the seminal fluid may cause contractions that could be painful and also counterproductive to the sperm trying to swim up to reach an egg.

When buying donor sperm for an In Vitro Fertilization (IVF) cycle, we suggest buying ICI prepared sperm. It is less expensive and our laboratory will have to process the sample regardless if it is ICI or IUI prepared sperm for use in IVF.

If a sperm sample thaws with less live sperm than guaranteed by the bank, (an event that we occasionally see) we will give you a report that you can take to the sperm bank for a refund. Their liability however, is limited to the amount you paid for the sample. We therefore recommend that you buy more than one vial of sperm at a time, and suggest that you buy sperm that was frozen on different dates. This will minimize the chance that you will end up with sub-optimal sperm on the day of your insemination. Couples undergoing IVF with donor sperm should always have a minimum of 2 vials on hand for their cycle, even though we usually only need one.

If you have sperm left over after your cycle, you cannot return it to the sperm bank for a refund. You can continue to store it at PFC and you will be billed annually for the cost of storage (currently $400 regardless of how many vials you have stored). The sperm banks will also store the sperm for about the same storage fee, or you can ask for it to be discarded if you no longer need it. Bear in mind however, that the same donor may not be available the next time you want to get pregnant. If you are hoping to have two or more children that will be true genetic siblings, you may want to stockpile some sperm from your favorite donor.

On May 25, 2005 new FDA regulations go into effect that will drastically change certain areas of Assisted Reproductive Technology. At PFC, we feel it is important for our patients to understand the implications of these regulations and the effect they may have on their fertility care. We have created an in-house task force to not only ensure that PFC is in compliance with these new regulations, but also to provide patients with as much information as possible. While these new FDA laws will require more time and expense on the part of patients and clinics, federal law mandates that we adhere to them.

These new FDA requirements will affect the infectious disease screening of egg and sperm donors and individuals using gestational carriers. The law as currently written also will affect couples that may wish to donate their frozen embryos to another individual at some time in the future. The source of the eggs or sperm must be screened in accordance with the new rules if the eggs are retrieved or sperm collected on or after May 25, 2005 at any IVF clinic or sperm bank in the United States.

In compliance with California State laws PFC currently performs infectious disease testing on all individuals involved in IVF as well as sperm donors for intrauterine insemination (IUI). The FDA regulations apply to any situation in which eggs or sperm (or the resultant embryos) from an individual are being placed into another person with whom the source is not sexually intimate. The FDA requires screening for some diseases such as Jacob-Creutzfeldt disease and cytomegalovirus that California does not. Screening involves review of medical records, an interview, physical examination and testing.

The most difficult of the federal requirements is that testing must be performed within seven days of collecting the sperm or eggs. This means predicting the exact day that an egg retrieval or IUI will take place and relying upon sometimes slow outside reference laboratories to send test results back quickly.

The embryo transfer or IUI CANNOT OCCUR until the results are received and the donor(s) determined to be eligible. If results are not available by the day of scheduled embryo transfer, transfer may be postponed up to day 5 (blastocyst transfer) or ultimately cancelled. The embryos would be frozen for transfer at a later date. IUI’s with donor sperm would have to be cancelled if results are not available.

In an effort to minimize the likelihood that a retrieval or IUI will be cancelled and to maintain compliance with FDA and California regulations, PFC will continue to perform infectious disease testing on ALL IVF patients, egg donors and sperm sources (IVF & IUI) prior to cycle commencement. Individuals subject to FDA screening will complete the infectious disease questionnaire and physical examination. Within seven days of the anticipated egg retrieval or IUI, a second set of infectious disease tests will be done. Sperm sources will be requested to freeze a sperm sample within seven days of the initial screening as backup in case the second set of tests are not available on the day of retrieval or IUI. For couples wishing to maintain the option of donating their embryos in the future, the egg and sperm sources will need to be retested six or more months after the egg retrieval.

PFC staff are working to identify outside reference laboratories that meet the FDA criteria and that will provide quick turn around time at reasonable cost to our patients. Your clinical coordinator in conjunction with the PFC FDA Task Force will address any concerns you may have on this issue.

– PFC FDA Task Force

Q:
Can I collect my sperm at home and store it in my freezer? I have heard there is a kit that allows me to do this?

A:
There are collection and storage kits that allow you to initially collect and freeze your sperm specimen at home, but are not intended for storage in your kitchen freezer. The necessary temperature for maintaining sperm viability is far colder than a home freezer maintains. Specialized kits sold by only a few andrology clinics are designed to let you manage the collection process in the comfort of your own home. They can be purchased and shipped to you for about $350. (Please go to www.nwcryobank.com). These kits maintain the necessary frigid temperature for up to about a week, providing plenty of time to store several specimens for return to the andrology clinic. The kits include the necessary sterile implements for collection.

Naturally, home sperm collection is preferable over visiting a clinic, but freezing sperm is rather involved, and requires a great deal of attention to detail. Be sure to carefully follow the clinic’s instructions.

If you decide this process is for you, here’s what to expect:
The kits usually contain several vials for collecting multiple specimens over several days, thus ensuring back-ups. The specimen must be collected through masturbation using no lubricants, to avoid contamination. Once collected, the sample needs to sit at room temperature for 30 minutes while enzymes in the seminal fluid allow the initially thick sample to become more liquid.

Then the sample needs to be mixed with cryoprotectant, or antifreeze, which should be prepackaged inside the vials included in the sperm collection kit. The antifreeze must be separated from the sperm before insemination.

Do not attempt to freeze and thaw the sperm on your own for home insemination. Only an andrology lab can perform the critical step of extracting the sperm from the antifreeze upon thawing.

Also, even if you know that the sperm is of good quality, it is important to know how well it tolerates freezing and thawing. Your infertility clinic or a sperm bank can provide you with valuable information on the quality of the sperm and its capacity to withstand freezing. Results can be extremely variable. Northwest Andrology reports that on average, healthy normal sperm in one out of ten men simply do not hold up to cryopreservation. Poor sperm survival rates can greatly impact the outcome of IUI, which requires more sperm than other procedures like IVF and IVF with ICSI.

Unfortunately, there is no “in between” process that allows for short term home freezing in one’s freezer for out-of-town moments, or other reasons. And timing fresh sperm for home insemination also requires a certain degree of precision. If the sperm provider cannot be there at the exact time he is needed, the sperm will die in the seminal fluid fairly quickly. If fresh sperm are to be used, it is necessary to do the insemination within an hour or two of collecting the sample.