Midwives doing IUI

No, this is not the story that got away from me last week. I'm still not sure when I'll have that for you. But this is something I've been wanting to write about ever since someone mentioned to me that American midwives do IUI.

Really? Midwives doing IUI? That was news to me. 

In some US states, it's not just doctors who offer intrauterine insemination — midwives do too. And they do it in your own home, whenever you are most fertile, and for just a few hundred dollars a go.

Anyone can do non-intercourse insemination at home. Some sperm, fresh or thawed, is simply placed into the vagina, usually using a special syringe or cup. Intrauterine insemination (IUI) is different. It involves inserting a long, flexible, sterile tube through the cervix. Sperm that has been "washed" — separated from its seminal fluid — is piped directly into the uterus. From there, with luck, it makes its way to an egg and fertilizes it. 

"As a medical procedure, it's not complicated," says Kristin Kali, a midwife in Seattle, Washington. "It's slightly more complicated than a Pap smear, because you're going through the cervix and you have to maintain sterility of that catheter, but less complicated than placing an IUD." 

Kali's business, MAIA Midwifery and Fertility Services, is possibly the only midwifery practice in the US to focus almost exclusively on conception and fertility. Many others, however, in California, Vermont, New Hampshire, Maine and elsewhere, include fertility care to varying degrees in the more traditional midwifery mix. 

Just as midwives do birthing differently than doctors, they do fertility differently too. 

For one thing, midwives pay very close attention to the timing of ovulation. An acute increase in luteinizing hormone (LH) precedes it, and while an egg is usually released over the next day or two, everyone is different. Some people have only a short window of opportunity — as little as 12 hours following the "LH surge" — so midwives spend time teaching people how to recognize what happens in their own bodies. 

And because their hours are flexible, midwives can act on that intel. 

"Fertility doctors aren't on call for their patients," says Katarra Shaw, of Luna Madre Midwifery, based in Chico, California, "and we are." Shaw, like Kali and others, will do IUI when the odds are best — even if that happens to be in the evening, on a weekend, or in the middle of night.

Typically, midwives travel to a person's home, and do the procedure there. "It's a more comfortable environment," says Jennifer Ross, of Lionheart Midwifery in Dover, New Hampshire. "People can relax a little bit more." Their partners may be there, their pets are around. It's intimate, rather than clinical, she says.

Many people who prefer midwives to deliver their fertility care are queer, trans, single, or same-sex. "I can only guess that entering parenthood from a place of feeling central to the process and believing that your body works means that people feel more empowered," says Kali. "But it's not just lesbians and trans folks who need this. There are heterosexual people with male infertility or second marriage and he got a vasectomy after the first. There's all kinds of reasons that people might need donor insemination."

Despite the fact that midwives in several states perform IUI, and at least two midwifery schools, in Utah and in Maine, offer some instruction in it, midwifery-led IUI in the US operates in a bit of a grey zone. Some states, like California, include "preconception" care in a midwife's scope of practice, but no state specifically mentions IUI. 

Kali learned the skills from other midwives, as did Shaw, but also studied independently and in andrology labs. Ross got theoretical training at midwifery school in Utah, but learned hands-on from other midwives in California. In general, midwifery training, certification and regulation is diverse across the US. "When you look at a midwifery school curriculum," says Kali, "we all learn gynecology. This could easily be integrated into existing curriculum. It's just not."

Kali began offering IUI six years ago, through a mechanism called "expansion of clinical practice." It's a way for midwives to respond to unmet needs in the community, with a nod from the professional association, Midwives Association of Washington State. Midwives have to demonstrate that the need exists, that the practice is safe, and that they have the skills to do it. A medical doctor has to sign off. Another midwife had previously used the process to provide nitrous oxide for pain relief in labour. "I did the same with IUI," says Kali.   

Over the years, hundreds of babies have been conceived with the help of MAIA Midwifery. "I've just done it," says Kali. "And honestly, that's just how a lot of midwifery looks in the United States."

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