The night Eva and Christine conceived their daughter was magical. After tracking Christine’s fertility cycle for months and several previous failed attempts to conceive, Christine’s temperature and other factors told them it was time to try again. The moment of peak fertility struck in the middle of the night. They called their midwife, who woke up and came immediately to their apartment. Using frozen sperm they’d purchased from a sperm bank—the donor’s impressive academic pedigree was the selling point, Eva said, but his wavy dark hair didn’t hurt, either—the midwife inserted a speculum into Christine’s vagina, snaked a thin tube directly into her uterus, and readied the vial of sperm.
“Do you want to make the plunge?” the midwife asked, offering the reigns to Eva. So Eva pressed the plunger to inject the sperm into her wife’s uterus, and 10 months later, their daughter was born. Both women say that it was the happiest day of their lives.
Midwives have supported women during pregnancy and labor for centuries. Over the past decade, however, a lesser-known subculture of midwives has quietly branched out from delivering babies to helping create them—with at-home intrauterine inseminations. For lesbian couples, single or transgender women, and heterosexual couples with minor fertility issues, these home inseminations can be a low-risk, intimate, and empowering option. Unlike intracervical or intravaginal inseminations (think turkey baster), intrauterine inseminations deposit washed sperm directly into the uterus and have a success rate that is roughly two to three times higher than that of intracervical insemination. (These success rates are based on procedures done at clinics, not at home.) At a doctor’s fertility clinic, some women say the insemination experience can feel clinical, perfunctory, or rushed, but at home conception can be comfortable, personal, even romantic. And some women hope to avoid the fertility drugs, such as clomid, that many physicians use to inseminate all patients, even ones who don’t have fertility problems.
“We’re not opposed to prescription medications or regular doctors,” said Amanda, who conceived her first child through home intrauterine insemination. “But the important thing for us was to find care that didn’t have unnecessary medical interventions involved. When we first went to clinics, they immediately wanted to pump me full of all kinds of drugs even though I didn’t have any known fertility problems. I was like, ‘Wait, can’t we try this naturally first?’ ” Amanda’s hunch that drugs weren’t necessary turned out to be spot on: At home, with a midwife, she and her wife conceived on their first try.
Home insemination is also a valuable refuge for women who have been turned away from traditional fertility clinics because they are unmarried or in same-sex relationships. And since many health insurance plans don’t cover intrauterine inseminations at all (or won’t cover inseminations for women who need them for reasons other than infertility), it’s often simply more affordable to have the procedure performed by a midwife, many of whom offer sliding-scale fees for low-income families. As legal and social progression empowers more women to consider having children regardless of whether they happen to be married to a man, home intrauterine insemination is poised to become an even more popular choice.
“I really get the sense that more people are starting to think of this as a viable option for having children,” said Gina Eichenbaum-Pikser, a certified nurse midwife in New York City who offers home intrauterine inseminations. “The old barriers to starting a family, like having a same-sex partner or no partner at all, are falling away. It’s wonderful.”
It is wonderful. But here’s the catch: No one is regulating midwife-performed, at-home intrauterine inseminations. Due to the U.S. government’s fractured relationship with midwifery—it’s legal and regulated in some states, neither legal nor illegal in some, and actively prosecuted in others—the procedure of intrauterine insemination has simply fallen through the cracks. The most widely recognized midwifery accreditation, the CPM (certified professional midwife), doesn’t teach or evaluate intrauterine insemination. Neither does the California Licensed Midwife exam. Not even the nurse midwife programs at many schools of nursing nationwide require training in intrauterine insemination. In fact, I couldn’t find a single formal midwifery training process that mandates inclusion of the procedure in its instruction course or final evaluation.
“It’s not one of our core competencies,” said Debbie Pulley, director of public education and advocacy for the North American Registry of Midwives. “Our certification is based on the main skills that midwives need to care for a mother in the pregnancy, birth, and postpartum periods.” Pulley added that she is not aware of any effort to have intrauterine insemination added to the basic certification process. So midwives learn how to perform intrauterine inseminations the old-fashioned way: They teach one another.
This isn’t as worrisome as it might sound. Most midwifery is taught in an apprenticeship model, so the vast majority of a midwife’s skills are already learned on the job, passed down from one midwife to another. (This apprenticeship-style on-the-job training, by the way, is frankly not that different from how physicians learn most of their skills.) And a midwife’s formal training already includes the knowledge and skills that are required to safely perform intrauterine inseminations, such as how to insert a speculum, navigate obstetric and gynecological anatomy, and use sterile technique. That knowledge translates easily to the intrauterine insemination procedure, which is a natural and logical extension of the broader home-birth movement.
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