Why might someone use donor sperm?

‍

There are multiple scenarios in which the use of donor sperm may be indicated.ⁱ These include the following:

• Significant sperm abnormalities, such as severe oligospermia (decreased sperm count in ejaculate) and azoospermia (no sperm in ejaculate)
• Failure of successful fertilization using in vitro fertilization (IVF) despite the use of intracytoplasmic sperm injection (ICSI)
• Ejaculatory dysfunction
• An individual has (or is a carrier of) a severe genetic disorder that could be passed on to offspring
• The person or people wanting to become parents do not have a partner that makes sperm, such as in the case of a single cisgender woman, a same-sex cisgender female couple, or a transgender male with or without a partner

A 2014 study published in the American Journal of Obstetrics & Gynecology found that 6.2 percent of assisted reproductive technology cycles in the U.S. used donor sperm.ⁱⁱ And a national survey from 2015-2017 found that donor sperm was used by up to 0.69 percent of all reproductive-aged females in the United States.ⁱⁱⁱ

Emotional considerations of using a sperm donor

While it can be beneficial for individuals and couples, sperm donation also brings up complex emotions for the intended parents. Some males perceive sperm donation as a threat to their masculinity, since fertility is often associated with male sexual potency. Men may also feel guilt surrounding their inability to successfully achieve a pregnancy with their partner.^iv Women may find the use of a sperm donor challenging as well. One study by Patel et al (2018) found that women reported hesitancy over the procedural strain of using donor sperm, as well as fear that their spouse or their family members might reject, abuse, or neglect them or the child born out of the use of donor sperm.^v

Other individuals experience a grieving process when using a sperm donor, because sperm donation prevents a biological or genetic tie between the male partner (if there is one) and offspring. Intended parents may also experience anxiety about disclosing the use of a sperm donor to their child in the future.^vi

Counselling and mental health support can be helpful for individuals using a sperm donor and should be encouraged. One 2020 study published in Reproductive BioMedicine Online found that 55 percent of women who used donor sperm reported unmet counselling needs.^vii

‍

What should one look for in a sperm donor?

‍

When facilitating sperm donation, fertility clinics typically utilize a rigorous screening process and variety of tests that help improve the chances of a successful match between donor sperm and the intended parents. These tests include semen analysis, genetic screening, and medical and laboratory testing. Whether the sperm donor’s identity can be disclosed depends on several factors that vary by location and situation.  

Semen analysis

Semen sample analyses are done to ensure the sperm is of adequate quality for donation. The analysis looks at sperm count, concentration, motility, and morphology (shape/appearance). A sperm donor must abstain from all forms of ejaculation for 2-3 days prior to providing a semen sample, which is typically collected via masturbation.^viii  

Maintaining a short period of abstinence prior to donation has been shown to improve certain sperm quality parameters at the time of collection. A study by Comar et al (2017) found that 2-5 and >5 days’ abstinence produced the greatest semen volumes and sperm concentrations when compared to 2 days’ abstinence.^ix

Genetic screening for sperm donors

Sperm donors typically undergo genetic testing prior to donation in order to reduce the chances of having offspring born with genetic disorders. The number of genetic variants (mutations) for which a donor is screened varies considerably by fertility clinic, egg bank, agency, and even country. Some agencies require the potential sperm donor to undergo a complete chromosome analysis prior to acceptance as a donor. Recipients should ask about the details of the genetic screening panel used for sperm donors when choosing a donor.^x

Genetic screening is important because even if a potential sperm donor does not have any symptoms of a genetic disorder, he may be a carrier of certain genetic conditions. If the egg provider is also a carrier of the same genetic condition, the embryo has a higher risk of developing that particular disorder. It should be noted that being a carrier for a genetic disorder is not the same as having the disorder.

Medical history

A detailed account of the sperm donor’s personal health history will be obtained prior to sperm donation, including the donor’s individual risk of infectious diseases, genetic conditions, and other disorders. Individuals at high risk for HIV or sexually transmitted infections (STIs) are not usually accepted as sperm donors.^xi Information about the donor’s family will also be obtained in order to look for conditions that have a genetic component that could be inherited in the offspring.

Sperm donors’ age is also an important factor when determining eligibility. Men can typically donate sperm up until age 40, due to an increased risk of certain genetic disorders in offspring from men of advanced paternal age. However, some fertility clinics and sperm banks set other age parameters.^xii

Laboratory testing

Prior to and throughout the sperm donation process, sperm donors must provide blood and urine samples that will undergo laboratory testing in order to assess for STIs and other transmissible diseases. Blood tests for syphilis, hepatitis B, and hepatitis C are completed at the initial screening and should be repeated every six months. If an individual is positive for hepatitis B or hepatitis C, he should be excluded as a sperm donor. Urine tests for chlamydia and gonorrhea will also be completed at initial screening. If positive, they should be repeated after treatment and prior to sperm donation.

Testing for cytomegalovirus (CMV) should be completed initially and repeated every six months as well. If positive for an active infection, the individual will not be eligible for sperm donation. Sperm donation from a man who is CMV seropositive (without an active infection) can still be used after appropriate counseling. Testing for human immunodeficiency virus (HIV) and human T-lymphotrophic virus (HTLV) should also be completed and repeated every 6 months.^xiii

Sperm donor anonymity

Sperm donors may be anonymous (closed ID), semi-anonymous/semi-open (limited information about the sperm donor is disclosed), open ID/identity release, or known/directed. Some countries require all sperm donations to be anonymous, other countries require all donations to be open ID, and still others offer both options. In the United States, most sperm donors are anonymous, and there is no legal obligation for donor identity disclosure.^xiv With the rise of publicly available genetic/ancestry testing, children conceived from anonymous donors are likely to be able to identify their donor and any biologically related relatives by submitting their DNA to available databases. Thus, donor anonymity is a moving target, and donors opting for this route should be counseled that there is a high likelihood any children that result from their donation may be able to find them in the future.

In the case of open ID sperm donors, the identity of the sperm donor (identity release) might not be revealed to the donor-conceived child until they are 18 years old. Known donors, who are sometimes a relative or friend of the intended parents,^xv generally allow for more frequent communication between the sperm donor and the intended parents.

‍

How to choose between fresh vs frozen donor sperm?

‍

Usually, donor sperm samples are frozen and subsequently thawed prior to intrauterine insemination (IUI) or IVF. Frozen sperm allows for sperm banking and storage and allows time for the donor to be tested again for transmissible infections prior to insemination. The freezing and thawing process is highly controlled to prevent damage to the sperm.^xvi In general, fresh sperm transfer is not recommended due to the risk of transmission of disease if the donor finds out he is seropositive for a communicable infection after the semen has been used for insemination. This can be true in the case of some STIs, such as HIV, where initial testing of an HIV-positive individual may be negative before turning positive several months later. Thus, the American Society of Reproductive Medicine (ASRM) recommends that fresh semen only be used in the case of sexually intimate partners.^xvii

‍

How many vials of sperm are needed? 

‍

Fertility clinics generally require different amounts of donor sperm depending on the assisted reproductive techniques used. For example, clinics may set different sperm parameter goals for use in IUI versus IVF; fewer sperm are often required for use with IVF. Both the number of sperm and quality of sperm are utilized to determine if sperm collections are adequate for use in donation. For IUI, parameters including motile count after washing of at least 0.8 - 5 million, percentage of normal sperm morphology ⩾5 percent, total motile sperm count of >5-10 million, and total sperm motility >30% have been suggested in various reports.^xviii However, there is no consensus on exact values and each center is likely to have slightly different criteria.  

Once the appropriate number of vials has been determined and it is time for the sperm to be used in IUI or IVF, the vials are thawed (if frozen) and the sperm samples are washed in an inexpensive quick procedure known as washing. This is done to concentrate the sperm into a smaller volume and remove other components of the seminal fluid that may interfere with fertilization.^xix  

In the case of frozen samples, the entire vial of sperm may not be thawed at once. This is known as partial thawing or “shaving” of the donor sperm. It is completed by shaving a small amount of frozen sperm from the vial and conserving the rest of the vial for later use. A 2018 study in the Journal of Assisted Reproduction and Genetics involving 198 patients showed that while partial thawing does not affect fertilization rates, the number of high-quality embryos created with the shaving technique is significantly reduced. Therefore, this technique is not typically recommended and is only used if the amount of sperm from the sperm donor is limited. Similarly, repeated freeze-thaw cycles of the sperm are not recommended as this significantly affects motility.^xx However, dependent upon the intended parents and the availability of a sperm donor, there may be no choice other than to use the shaving methodology. This is especially important if trying to create genetically matching siblings with limited availability of sperm from the first donor.

‍

What are the treatment options when using donor sperm? 

‍

Donor sperm is used in various assisted reproductive techniques, which are selected based on the intended parent’s preference and personal medical history. The most common fertility treatments involving donor sperm include IUI, IVF, and IVF with intracytoplasmic sperm injection (ICSI).  

IUI with donor sperm

IUI involves the injection of sperm into the uterine cavity. The goal of IUI is for the woman’s own egg to become fertilized by the donor sperm, whereafter the embryo implants into the uterine lining to achieve pregnancy. IUI is performed at the time of female ovulation.^xxi

IUI is considered both cost-effective and non-invasive and is often the first-line therapy for infertility related to cervical factors, mild male factor infertility, infertility due to a lack of ovulation treated with medication, unexplained infertility, and same-sex female couples or women without partner sperm. A large 2020 observational study published in BMJ Open showed that IUI had a live birth rate of 12 percent per cycle, though the success varies significantly in accordance with female age and type of infertility.^xxii

IVF using donor sperm

IVF is the process by which a woman’s egg is mixed with donor sperm in a laboratory dish. Once fertilization occurs, the embryo is then cultured in the lab and transferred to the uterus of the recipient of the embryo.  

IVF may be completed with ICSI, in which a pre-selected sperm cell from the sperm donor is injected directly into the egg. It is especially useful in male factor infertility (MFI) because it overcomes the process of sperm cells having to swim to and penetrate the egg on their own. However, ICSI is becoming more and more common even in the absence of MFI.^xxiii

‍

Who carries the pregnancy? 

‍

The person who carries the pregnancy is the recipient of the embryo fertilized by donated sperm, whether by IUI or IVF. This person will either be a female intended parent who used IUI or IVF, or a gestational carrier in the case of IVF only.

Intended parent

If the intended parent plans to carry the pregnancy, she will need to undergo pre-pregnancy investigations prior to embryo transfer or IUI. This includes a detailed review of the intended parent’s medical, surgical, and psychiatric history, medication and substance use, and medical family history. The pre-pregnancy investigation also includes a physical exam to ensure that the recipient is a good candidate for carrying a pregnancy.  

Ultrasound imaging of the uterus using a sonohysterogram is often performed to look for uterine conditions that may interfere with pregnancy. Blood tests are also completed to determine blood type, vaccination status, and hormone levels, and to test for infectious diseases.^xxiv

Gestational carrier

A gestational carrier is a woman who has an embryo transferred to her uterus for the purpose of carrying the pregnancy on another person or couple’s behalf. Embryos transferred to a gestational carrier’s uterus may be created using a sperm donor.  

A gestational carrier may be used if the intended parent is unable or unwilling to carry out a pregnancy. There are various reasons for this, including medical conditions where pregnancy is contraindicated (e.g., poorly controlled high blood pressure), uterine conditions (e.g., absence of a uterus or a significant uterine abnormality), or logistical or personal reasons for not desiring a pregnancy.^xxv

In traditional surrogacy using donor sperm and the surrogate’s own eggs, IUI can be performed. However, this is no longer a common practice. More often, a gestational carrier is used so that the woman carrying the baby does not have a genetic connection to the child.

‍

What are the success rates for using donor sperm?

‍

Reported success rates in achieving pregnancy with donor sperm vary depending on the oocyte age and the population to which embryos fertilized with donor sperm are compared. One 2017 study published in Original Research Gynecology found an increased live birth rate in assisted reproductive cycles using donor sperm compared to cycles using non-donor sperm, after adjusting for maternal age.^xxvi Another 2017 study with 402 patients who underwent a total of 1 264 IUI cycles found that the clinical pregnancy rate was 17.2 percent per IUI cycle with frozen donor sperm.^xxvii

More recently, a 2021 study published in Human Reproduction analyzed 3 910 IVF cycles in women ≥ 40 years old. 307 of those women underwent IVF with donor sperm and the rest used non-donor sperm. The researchers found that the rate of pregnancy with donor sperm was 41.0 percent compared to 39.8 percent in patients who used non-donor sperm, which was not found to be a significant difference. The researchers did find, however, that there were significantly higher odds of having a live birth in women ≥ 40 years old who used a sperm donor compared to non-donor sperm.^xxviii

‍

Conclusion

‍

Couples and individuals interested in sperm donation should speak with their fertility clinic or medical team for more information and should consider asking for a referral to a mental health professional experienced with third-party reproduction who can ensure patients are adequately supported through this process. Both the decision to use donor sperm as well as the decision to be the donor require a great deal of thought and decision-making, and the proper counselor can ensure that all involved are asking the right questions and getting sufficient answers.

‍