Views and reviews: therapeutic donor insemination.

Therapeutic donor insemination (TDI) is an important method to achieve the family-building goals of single individuals, same-sex couples, and those requiring otherwise donor gametes (azoospermia, etc.). This review addresses key clinical considerations in TDI management, focusing on estimation of live birth rates, cost-effectiveness strategies, and when to move toward in vitro fertilization (IVF). When counseling patients, discussion may be grounded in exploration of natural fecundability. For patients whose sole indication for TDI is need for gamete exposure, per-cycle live birth rates with natural cycle TDI approximate those of age-matched natural conception, ranging from 18%-20% aged <37 to <5%-10% aged ≥40, with cumulative rates across six cycles of 50%-60% and <10%-15%, respectively. Success diminishes substantially after age 42 and may be considered futile aged >45. Empiric ovulation induction in younger, ovulatory patients without additional infertility diagnoses offers minimal improvement in cumulative live birth rates while significantly increasing the risk of multiple gestations; therefore, the universal implementation of ovulation induction should be avoided and evaluated on a case-by-case basis. Cost-effectiveness can be enhanced through avoidance of unnecessary ovulation induction in favorable-prognosis patients, utilization of home urinary luteinizing hormone monitoring, performance of a single insemination per cycle, and minimization of unproven adjunctive therapies-reducing per-cycle expenditures without compromising outcomes. The transition to IVF should be individualized through shared decision-making. In younger patients (<35 years), cumulative live birth rates across three natural TDI cycles (50%-60%) may approximate a single IVF cycle (40%-50%), supporting an initial trial of TDI. For patients of advanced reproductive age (≥40 years), earlier transition to IVF should be considered given diminishing returns with additional cycles. Patient preference, treatment fatigue, and desire for shorter time to pregnancy should remain central to decision making.