Queer & trans folks have always built their families through creativity, ingenuity, and force of will, and now more than ever, those of us who have uteruses in the family have a wide range of options for growing our families by conceiving and carrying our babies ourselves. When you’re conceiving in ways that don’t involve PIV sex, it’s all about setting the scene for the gametes (reproductive cells, i.e. sperm and eggs) to find themselves in the same place at the same time. Timing is a big piece of the puzzle, and you can read about the ways we can track ovulatory cycles and time inseminations in this article I wrote for Family Equality. The variety of insemination methods and IVF processes available are not always very clearly defined or easy to understand, so I’m going to walk you through all of these options and what they entail!
Intra-Cervical Insemination (abbreviated to ICI) is essentially what you think of when you think of the “turkey baster method” but there’s many better tools than turkey basters for this purpose. ICI can be done at home using fresh or frozen sperm, and using tools like a needleless syringe, a soft-disc style menstrual cup, and fertility lubricant. The process (using fresh sperm) might look like this:
Regardless of what your ICI ritual might look like, there’s a few details that can be helpful to consider. Fresh sperm can live inside of the body after insemination for around 5 days, but frozen sperm will only live for about 24 hours. This means that there’s a little more flexibility around timing when you’re using fresh sperm. Also, when using fresh sperm, it’s best that it’s exposed to the air for as little time as possible after it is expelled from the donor’s body. This means that it is best to plan on doing the insemination in the same location as the donation is made.
Intra-Uterine insemination eliminates a significant variable in the gametes finding each other equation- the variable of sperm finding their way through the cervix. In Intra-Uterine insemination, a needleless syringe and small catheter tube are used to bypass the cervix, and deposit the sperm directly into the uterus. IUI is usually done with the assistance of a midwife at home or in-clinic, or by a reproductive endocrinologist in a doctor’s office. IUI can be done using fresh or frozen sperm, and must be done using sperm that’s been “washed.” Because IUI bypasses the cervix, only the sperm cells themselves can be used. Part of the job of the cervix and cervical mucus is to filter out anything other than the sperm cells, i.e. seminal fluid and any bacteria that may be coming with it. Only sperm cells should cross the barrier of the cervix into the inside of the uterus, and a chemical process called sperm washing can be used to separate those sperm cells. Sperm washing can be done by a midwife or reproductive endocrinologist at the time of the IUI, and cryobanks offer specific vials of washed sperm for IUI.
While IUI eliminates variables around getting the sperm and eggs to the same place, the variables around getting them there at the same time are still in play. But with ovarian stimulation, drugs are used to stimulate and trigger ovulation in order to eliminate some of the variables of timing. Ovarian stimulation drugs can be prescribed by some midwives and by reproductive endocrinologists. Commonly used drugs for ovarian stimulation are Clomid (clomiphene citrate) and Letrozole (an aromatase inhibitor). Both Clomid and Letrozole are administered as a tablet taken by mouth once a day for about 5 days near the beginning of a cycle. It’s also common to use a “trigger shot” of hCG (human chorionic gonadotropin) administered by injection to initiate the release of eggs from the ovary into the fallopian tubes. This drug regimen is prescribed and monitored by the care provider and the IUI is timed accordingly.
In-Vitro Fertilization (meaning fertilization in the lab) eliminates many of the variables around time and place by using medicine to take charge of almost every step of the process. IVF is a complex series of medical interventions that are managed by a reproductive endocrinologist in a doctor’s office. IVF entails a lot of steps and different medications, so let’s break it down:
Before any IVF cycle begins, there are lots of tests to be done. Reproductive endocrinologists will use bloodwork and ultrasounds to find out more about the ovaries of the person who will be utilizing their eggs, and the uterus of the person who plans to carry the pregnancy. The sperm that will be used will also be tested for sperm shape, size, and numbers. In some cases, a trial cycle will be recommended, where meds and monitoring will be done, but the egg retrieval or embryo transfer will not.
During ovarian stimulation, synthetic hormone injections, commonly referred to as “stims” (Follicle Stimulating hormone aka FSH and Luteinizing Hormone aka LH) are used to stimulate the ovaries to mature many eggs at once. For most, it takes one to two weeks of ovarian stimulation to mature many eggs, getting them ready for the next step- egg retrieval. Throughout the ovarian stimulation stage, the maturation of the eggs is monitored using intragential ultrasound, which is used to view the ovaries and monitor the development of follicles (each egg develops inside of a follicle on the ovary). A “trigger shot” of hCG will be given as a last step of ovarian stimulation. Sometimes, another medication is used to prevent the follicles from releasing the mature eggs.
The egg retrieval procedure is done when monitoring shows that the follicles are looking large enough that they likely contain mature eggs. The person whose eggs are being retrieved will be given an IC sedative medication. The reproductive endocrinologist will use a transgenital ultrasound to identify the follicles on the ovary, and then inserts a long, thin needle into the ultrasound device. The needle is guided through the inside of the genitals toward the ovary, and the eggs are removed from the follicles using a suction device that’s attached to the needle. The procedure takes around 20-30 minutes, and many eggs (8-14 on average) may be retrieved in that time. The eggs are then placed in a nutritive liquid and incubated in the lab. After the egg retrieval procedure, the person intending to carry the pregnancy will likely begin a course of progesterone injections to prepare for the embryo transfer.
In IVF, fertilization happens in the lab. The doctors may use conventional insemination, where sperm is placed in a dish with the eggs, or may use intracytoplasmic sperm injection (ICSI) to insert a single sperm cell into a single egg. The latter is usually done if the number of sperm in a sample is low, or if previous conventional insemination has not resulted in a successful embryo.
Once the eggs have been fertilized, and if viable embryos have resulted, then comes the embryo transfer. This usually takes place 2-5 days after the egg retrieval if doing a fresh embryo transfer or sometime in the future if doing a frozen embryo transfer. For this procedure, the person intending to carry may be given a mild sedative. Using a process similar to IUI, the reproductive endocrinologist will insert a small catheter through the genitals and cervix and into the uterus. The embryo is transferred through this catheter into the uterus.
After the embryo transfer, the person intending to carry the pregnancy will continue the daily progesterone medications. About 12 days to two weeks after the transfer, the doctor will do a blood pregnancy test to confirm if the embryo has implanted and a pregnancy has begun. If the blood test finds that the carrying person is not pregnant, they would stop the progesterone medications and probably have a period within a week. If a pregnancy has begun, they will continue taking progesterone meds until around week 10-12 of their pregnancy.
In reciprocal IVF, or RIVF, the egg retrieval process is done with one parent, and another parent does the embryo transfer and plans to carry the pregnancy. This is just a little bit different than the traditional IVF process where the same person whose eggs are being used is also the person planning to carry. This makes it possible for the non-biological parent to be the gestational parent, and for multiple partners to make physical contributions to building their families.
With all of these options available, there are so many considerations that any family has to contend with as they’re planning. The financial investments involved in buying sperm or utilizing IVF are significant and very rarely covered by insurance. The emotional rollercoaster of multiple attempts and potential pregnancy losses is hard to imagine or prepare for. Ultimately, taking time to learn about the ins and outs of your options, and taking care to build your support networks ahead of time are important steps to preparing for the beginning of any family building journey. Fertility doulas like me are here to help you with all of this and more, so don’t hesitate to reach out for support at any stage of your process.