Optimizing the therapeutic donor insemination cycle

Therapeutic donor insemination (TDI) is a widely used and effective fertility treatment in which decisions around cycle management decisions aim to optimize pregnancy outcomes while balancing cost, access to care, and patient burden. Key aspects of care, including timing of insemination, monitoring strategies, use of ovulation induction, and luteal phase support, often are guided by institutional preference rather than definitive evidence. Accurate synchronization of insemination with ovulation is central to TDI success. Available approaches include urinary luteinizing hormone (LH) detection, serum LH monitoring, and ultrasound-based follicular tracking with or without ovulation triggering. Although these methods differ in precision and patient burden, current evidence demonstrates comparable pregnancy outcomes in most ovulatory patients. In ovulatory individuals, natural-cycle TDI yields favorable cumulative pregnancy rates. The addition of oral ovulation induction confers only modest improvements in pregnancy outcomes while significantly increasing the risk of multiple gestation. Accordingly, escalation to ovulation induction should be individualized. The role of luteal phase support remains incompletely defined, with current evidence not supporting its routine use in natural TDI cycles or those with oral ovulation induction agents. Overall, a pragmatic, patient-centered approach that prioritizes effective yet minimally burdensome strategies is supported by available evidence.