As we’ve discussed in our insemination section, there are many different options for lesbian couples who are interested in being biologically connected to their child. Depending on your situation, you may explore IVF, clinical insemination, or at-home insemination to get pregnant with sperm from a sperm bank or known donor. You will also choose whether to deposit sperm intravaginally (essentially simulating what happens during straight sex, when semen is deposited into the vagina) or to deposit “washed” or prepared sperm directly into the uterus (a procedure known as an IUI).
Many couples like the idea of inseminating at home instead of in a clinic, but may still want to do an IUI, as depositing sperm directly into the uterus tends to have better success rates in comparison to depositing semen in the vagina (typically done using a cervical cap or syringe). Performing IUI at-home is more complicated than IVI and involves the use of a thin catheter and knowledge of, well, where you’re headed and what you’re doing.
That’s where an experienced midwife who has knowledge and expertise with the IUI procedure can step in. We recently sat down with Brooklyn-based Certified Nurse Midwife Gina Eichenbaum-Pikser to discuss what to expect if you are interested in doing an IUI at-home as a lesbian couple.
IC: What are the first steps a lesbian couple should take to prepare for at-home insemination?
GEP: The first thing I would say is to make sure everything is lined up with where your sperm is coming from, because that actually can take longer than people think it’s going to take. So, depending on how you’re doing it, with a known donor vs. unknown donor, etc. certain sperm banks will require up to 6 months of sperm quarantine before sperm that’s been donated for you can be accessed by you. So there can be this sort of 6 month waiting period that a lot of people don’t anticipate if you’re using known donor sperm that’s being processed through a sperm bank or prepared for IUI.
IC: So there are basically three ways of doing it – you can get sperm from the sperm bank, you can have someone you know donate sperm to a bank for washing/processing etc., and then technically you can just have a guy you know come over and donate the day you are inseminating.
GEP: You could absolutely, [have a known donor just come over], but if you’re going to use fresh sperm – which is not just sperm, but semen – then you have to do what’s called an IVI, or intravaginal insemination. That’s because you can’t put fresh semen directly into the uterus because there’s a very high likelihood of infection – it’s dangerous.
The reason for that is that the cervix naturally filters the sperm from the semen and only allows sperm into the uterus – which is pretty amazing. So if you’re doing any kind of procedure that’s depositing sperm into the uterus than you have to, unfortunately, go through a sperm bank or another type of facility that can do what they call “washing” the semen, which then produces sperm you can use.
But you could do IVI, which you really don’t need anybody’s help to do, with fresh semen. So yes, if you had a donor or a friend or whoever who was willing to just come over and you guys could work that out however you felt comfortable – I’ve certainly known people to do that.
Editor’s Note: Be sure to read Diana Adams’ article on Sperm Donor Agreements before using known donor sperm.
IC: What type of equipment is needed for the IUI procedure vs. the IVI procedure?
GEP: For an IUI we use a really thin catheter, and to do IVI you wouldn’t really need that kind of thin catheter, you would really just need any kind of syringe. If you’re not planning on using a method that enters the uterus there are some cool things you can use to kind of keep the semen up by the cervix like cups and cervical caps. That is sort of in-between IVI and IUI because it does get it closer up to where it needs to be and it’s a way of keeping it up there which will increase the likelihood that it will pass through the cervix, but none of those collection cups will actually deposit it into the uterus.
When I perform IUIs, I bring everything with me. In terms of timing and ovulation and knowing when is an appropriate time for insemination there are a few different methods. I actually just recommend mostly using over-the-counter ovulation predictor kits. There are definitely natural ways of recognizing fertility and I recommend paying attention to those things as well – and those are things we could go over when I meet with the couple or a woman trying to get pregnant prior to starting the process. But, in general, I think a mix is good. If you use the OTC predictor kits and you test a few times a day you can actually narrow the window down pretty well to exactly when you’re going to ovulate – it’s easier to do with the predictor kits then just noticing the natural fertility signs. I don’t supply those – you can just get them at the drugstore. But otherwise I bring everything with me. Sperm, however, would need to be picked up by the woman planning to get pregnant or her partner.
IC: If you are getting sperm from the sperm bank, how does the delivery work? Are there different options?
GEP : Each sperm bank is probably a little bit different. The one that I’ve worked with won’t deliver the sperm to a residence. So if you’re having IUI done in a clinic or office they can deliver it there. If you’re doing it at home, then you need to pick it up from the sperm bank, which isn’t super difficult. They need a little bit of notice when you’re going to pick it up, but nothing unreasonable, because they know that you don’t get a lot of notice either.
When you pick up the sperm, it’s in a liquid nitrogen case that keeps the sperm frozen for 7 days. The idea is you want to time it well enough that you’re picking it up before you’ve ovulated, but not so far before you’ve ovulated that you’re going to need to keep it for more than a week. Although I do believe that if somehow your timing is off I think you can pick up extra liquid nitrogen if you need to keep it frozen for longer than 7 days.
IC: What if you’re working with a sperm bank across the country – are there places in New York where they can store it until you’re ready?
G: You most likely will be able to store it in a New York sperm bank. Also, if you have a known donor who lives in another part of the country, they can deposit their sperm in a sperm bank where they live and that sperm bank can ship it to one of the New York sperm banks who will store it for you for a certain fee.
IC: What is the advantage of at-home insemination, in your opinion?
GEP: I got into this business by helping a couple who are really dear friends of mine who wanted to get pregnant. They looked into doing it at a clinic and they felt that they really couldn’t afford the prices, so my offering to do it for them in their home had much more to do with the price of clinical insemination than the setting. But once we were doing it, we all realized how lovely and special and intimate it felt for this to be happening in their house. And, you know, everyone wants ideally to start a family in their home. It’s your space and it’s your process and it’s your timetable – and it’s just much more about you and more comfortable and private and special. So that’s what I see as the advantage of inseminating at home.
IC: What is your role as a midwife in the process? How can you help couples with at-home insemination?
GEP: In terms of my role, I know that if you go online there are sites that can talk you through doing IUI on your own, but I don’t really think that’s a great idea, I don’t feel super comfortable with that. Again if people wanted to try IVI – absolutely, you don’t need anybody’s help to do that – it’s super easy. But once you start talking about entering into the uterus you need to make sure you’re doing is safely and that everything is sterile. There’s not a whole lot of risk that comes with it, but it’s not really a cavity that’s meant to be entered. There’s not a natural process that involves entering the uterus – only exiting. So I think it’s a good idea to have someone who is trained and comfortable both with this procedure specifically but also someone who is comfortable with that anatomy and who has done procedures that involve entering the uterus before.
IC: How much do you charge for at-home insemination?
GEP: For me, I want insemination to be something that people can do not at an exorbitant cost. Because I think looking around at some of the clinics or going through a sperm bank, the prices can be really high.
I provide rates for at-home IUI and consultation on a sliding scale based on your income.
Editor’s Note: See Gina’s rates for at-home insemination
In terms of other costs – in addition to the cost of sperm and over-the-counter ovulation kits, there may be a shipping charge if you have sperm shipped from outside, as well as a storage fee from the sperm bank you are storing your sperm at nearby. If you are using a known donor’s sperm, the sperm preparation facility may charge for the testing, for washing/freezing, and a charge for shipping as well.
IC: Do you recommend getting certain fertility tests done before you start trying as a lesbian couple?
GEP: Not necessarily, it would depend. We’d have to have a little bit more of a conversation just in terms of individual history and menstrual history and all of that. The truth is, for most queer couples the issue is not a fertility issue. That’s the other part of going to a fertility clinic that I feel like is so problematic. This isn’t a fertility issue. I would say if the person planning to get pregnant has regular cycles, gets her period once a month, has never been told by any kind of healthcare provider they should anticipate any kind of fertility issues than no, I think to start off with paying for expensive fertility tests is pretty silly.
You know, if a heterosexual woman decides she is going to try to get pregnant, nobody suggests she start that process by getting a fertility workup. And yes, granted, paying for insemination, you know, there lends a small argument to having those tests done earlier rather than later because you are paying to try to get pregnant, but for me, I would think – and again that’s everybody’s choice if someone feels they want to start that way there’s nothing wrong with it – but I don’t feel like there’s really an indication for that unless you’ve been trying and it hasn’t worked.
IC: Would you say there’s an age limit where you would recommend a woman automatically get tested?
GEP: I would say it’s more based on your personal history. I mean, there’s a really wide range in when women’s fertility starts to change. It’s pretty personal. Let’s say someone who’s 36 has already started to notice some change in monthly cycles – I might recommend some tests. But you could have someone older than that who’s always had really regular cycles, and I wouldn’t necessarily recommend those tests. I don’t think it’s specifically age-related. It would be more menstrual history related.
IC: How should a couple prepare to get pregnant?
GEP: The majority of preconception counseling, is a lot of really common sense health stuff. All of the things you’ve said you wanted to do for your own health for years, now’s the time to really do it. So getting into a regular exercise habit, trying to eat a well-balanced, well-rounded diet, starting to take a daily prenatal vitamin or at least a folic acid vitamin is a good idea. There isn’t really anything specific about getting your body ready for pregnancy than there is about getting your body healthy. Exercise is recommended in pregnancy, but not for someone who’s never exercised before. So again if you’re not someone who really fits exercise into your daily routine, trying to start that before you get pregnant is a good idea. Changing your diet to healthy diet while you’re pregnant is super hard if that’s not something you’re used to – so just starting to think about those things before you get pregnant, and trying to make your body as healthy as a place it can be for pregnancy.
IC: What happens once you start ovulating?
GEP: Well there is a window. What you’re testing for is the warning signs of ovulation and not ovulation itself. So what ovulation kits test for is what’s called the LH surge, and that happens approximately 24 hours prior to ovulation. So when you get the positive test what that means is not, “I’m ovulating.” It means “Okay, in 24 hours, I’m ovulating.” There are also different ways of timing when to inseminate and how many times to inseminate. In general, I recommend two inseminations per cycle. The first one would be about 24 hours after you get that positive sign and the second one would be somewhere around 8-12 hours after that. So that notification window gives you about one full day to get in touch with me, figure out when I’m coming over (based on your schedule and based on my schedule), and then go pick up the sperm if you haven’t already. Now it’s possible if you have a really good sense of when you’re ovulating you’ll have already picked up the sperm, because you have it for 7 days.
IC: Do you need to warm frozen sperm, or can a couple do it?
GEP: It takes about 20 minutes for each vial to thaw. So what the couple will do is just leave it in the liquid nitrogen until I’m there and then we can just take it out together and let it thaw.
IC: How do you involve a woman’s partner in the process?
GEP: It’s totally up to them. The reason I’m there is to safely guide the catheter into the uterus. That’s really what I feel I’m there for. In terms of who pushes the sperm through the catheter and into the uterus ¬– it can be me, if that’s what they are most comfortable with – or it can certainly can be the partner – it’s up to them.
IC: Do you recommend orgasm after insemination?
GEP: If a couple is doing IVI – intravaginal insemination – I think it can help. What orgasm does is it makes the uterus contract and when the uterus contracts it has a bit of sucking faction that can help suck the sperm through the cervix and into the uterus. With IUI, you’re already depositing the sperm directly into the uterus, so I think in terms of the clinical value of orgasm it’s just a little bit less. But it can certainly be an experiential value, too. It can be more symbolic, more intimate and special, a way a couple can make it their process – so in that way I support it – obviously I would not need to be present for that (laughs). But yeah, in terms of clinical function it’s a little bit less helpful with IUI than with IVI.
IC: Is there any chance to get insemination covered by insurance?
GEP: This is the problem. I think it probably varies from insurance company to insurance company and I would highly encourage everybody to call and talk to them. But my understanding of most insurance company policies is that insemination falls under infertility treatment for everyone regardless of whether fertility is at play and in order to have it covered you need to prove infertility and proving infertility means you need to have 12 months – or 6 depending on your age – of unprotected heterosexual sex. So, for queer families that can be really problematic because there’s no way of proving infertility because infertility isn’t an issue, and also because nobody is having unprotected heterosexual sex. So, you know I think that until policies and laws change around this I think most likely people are going to have a really hard time getting covered by insurance.
IC: Is there any number of unsuccessful “tries” that you would actually recommend that a couple stop trying and get some testing done?
GEP: Taking anywhere up to 6 months is super normal and to be expected. Prior to 6 months I wouldn’t really recommend anything. Again, as always, if people wanted to have that done earlier, they could. After 6 months we would start having those conversations, and it would most likely be some kind of fertility workup.
Gina Eichenbaum-Pikser is a Certified Nurse-Midwife (CNM). After graduating from Columbia University School of Nursing in 2008, she began working as a full-scope midwife at Bellevue Hospital Center in Manhattan. She now also offers at-home and sliding scale gynecological services and IUI through her solo practice, Community Gyn Care. She can be contacted at Gina@communitygyn.com