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.
Still, several reproductive endocrinologists and other medical traditionalists I spoke with were surprised, even alarmed, to learn that midwives had branched out from pregnancy, labor, and delivery into intrauterine inseminations.
“I certainly understand the desire to have as pleasant an environment as possible in order to conceive, but I think most doctors try to provide that in their clinics,” said Dr. Eric Surrey, a board-certified reproductive endocrinologist and medical director with the Colorado Center for Reproductive Medicine. “Insemination is a medical procedure, and like anything else in medicine, it requires training. It’s not totally straightforward.”
While it’s true that the procedure has some potential risks—minor ones, such as cramping, and potentially life-threatening ones, such as infection or uterine puncture—those complications are extremely rare, both in home and clinical settings, and they are risks that an informed patient can choose to take. So the problem isn’t that some midwives offer home insemination options. Lesbian couples, transgender women, and single mothers deserve and are entitled to start their families on their own terms, in whatever environment is most comfortable for them, and midwives who offer home insemination services make that possible. The problem is that state governments should not and cannot legislate every variation of the safe ways women choose to conceive, carry, and deliver their children—but they’re trying to anyway. This unclear and inconsistent government interference in midwifery and alternative insemination has created a climate where even trained, professional, and law-abiding midwives often aren’t entirely sure what is or isn’t explicitly legal.
“I’ll teach someone how to inseminate her partner, but I won’t do it myself,” one midwife, who asked not to be named, told me. “I can’t jeopardize my home-birth practice over this.”
If the legality of providing inseminations is a gray area, the legality of receiving them is even murkier. In many states, only women or couples who receive inseminations under the care of a licensed physician, using a frozen sample from a sperm bank, are protected. Earlier this year, for example, a Kansas man who donated sperm to a lesbian couple was ordered to pay child support, largely because a physician did not perform the insemination. Laws vary state by state and in some cases are very problematic. In Minnesota, for example, Statute 257.56 says: “The donor of semen provided to a licensed physician for use in artificial insemination of a married woman other than the donor's wife is treated in law as if he were not the biological father of a child thereby conceived." The wording of "licensed physician" and "married woman," therefore, doesn't protect sperm donors who want to help unmarried women or those who inseminate under a midwife’s care.
“The legality of home insemination isn’t the only issue,” said Steven H. Snyder, an attorney who specializes in assisted reproductive technology law. “Statutes governing artificial insemination vary state by state, and if the state requires a doctor to inseminate, but instead a midwife inseminates, there could potentially be a lawsuit about the parentage of the resulting child.”
So what needs to happen? Home intrauterine insemination should be formally and officially included in the training courses for certified professional midwives, certified nurse midwives, and other licensed midwives so that providers of that valuable service are explicitly protected. On top of that, state laws need to be reformed to protect both the women who choose to inseminate at home and the known sperm donors who choose to help them. California took a step forward last year when Gov. Jerry Brown signed AB 2356, which ensures that women in same-sex relationships can access fertility services on the same terms as women in opposite-sex relationships. Now other states need to examine their own laws surrounding the fertility and insemination process to ensure that all women can start their families in whatever environment and with whatever licensed provider they choose.
“Yesterday I showed up a little bit early to an insemination, so first we sat out on her balcony, drinking tea and eating banana bread,” said Catherine Boshe, a certified nurse midwife who was first trained in home intrauterine inseminations by Eichenbaum-Pikser. “There’s just a connection that develops. It’s an amazing honor to be involved in such an intimate and important part of these women’s lives. Then, when they finally get a positive pregnancy test result, it feels like we’re celebrating for a good friend or a sister.”