Psychosocial aspects of identity-release gamete donation - perspectives of donors, recipients, and offspring

A systematic review of assisted and third-party reproduction guidelines regarding management and care of donors

BACKGROUND

Gamete and embryo donors face complex challenges affecting their health and quality of life. Healthcare providers need access to well-structured, evidence-based, and needs-based guidance to care for gamete and embryo donors. Therefore, this systematic review aimed to synthesize current assisted and third-party reproduction guidelines regarding management and care of donors.

METHODS

The databases of ISI, PubMed, Scopus, and websites of organizations related to the assisted reproduction were searched using the keywords of "third party reproduction", "gamete donation", "embryo donation", "guidelines", "committee opinion", and "best practice", without time limit up to July 2023. All the clinical or ethical guidelines and best practice statements regarding management and care for gamete and embryo donors written in the English language were included in the study. Quality assessment was carried using AGREE II tool. Included documents were reviewed and extracted data were narratively synthesized.

RESULTS

In this systematic review 14 related documents were reviewed of which eight were guidelines, three were practice codes and three were committee opinions. Five documents were developed in the United States, three in Canada, two in the United Kingdom, one in Australia, and one in Australia and New Zealand. Also, two guidelines developed by the European Society of Human Reproduction and Embryology were found. Management and care provided for donors were classified into four categories including screening, counseling, information provision, and ethical considerations.

CONCLUSION

While the current guidelines include some recommendations regarding the management and care of gamete/embryo donors in screening, counseling, information provision, and ethical considerations, nevertheless some shortcomings need to be addressed including donors' psychosocial needs, long-term effects of donation, donors' follow-up cares, and legal and human rights aspects of donation. Therefore, it is needed to conduct robust and well-designed research studies to fill the knowledge gap about gamete and embryo donors' needs, to inform current practices by developing evidence-based guidelines.

Israeli students' perceptions regarding sperm donation: dilemmas reflections with dominant demographic effect

BACKGROUND

Sperm donation has undergone significant medical and social transformations in recent decades. This study aimed to explore Israeli students' perceptions towards sperm donation and investigate the potential influence of demographic characteristics on these perceptions.

DESIGN

The study encompassed 254 students from Tel-Aviv University, who completed an anonymous online survey in January-February 2021. This cross-sectional quantitative online survey, comprised 35 questions categorized into three sections: demographic data, assessment of prior knowledge, and perceptions of sperm donation (general perceptions related to both positive and negative stigmas associated with sperm donation, the roles and activities of sperm banks, and considerations surrounding identity disclosure versus the anonymity of sperm donors and their offspring).

RESULTS

Participants exhibited a relatively low level of prior knowledge (mean 31.2 ± 19 of 100). Scores for positive and negative stigmas ranged from 1.3 to 2.2. Notably, the statement "Donors' anonymity preservation is crucial to maintain sperm donation" received a mean of 3.7. Seeking for anonymous sperm donation identity both by recipients and offspring was ranked with low means (1.5 and 1.7, respectively). However, the pursuit of half-siblings by mothers or siblings themselves received higher ratings ranging from 2.7 to 3. Women's stigma ranking were notably lower, while men emphasized the importance of donor anonymity.

CONCLUSIONS

Sperm Banks hold a position of medical authority rather than being perceived as being commercial entity. The preservation of donor anonymity is widely accepted as a crucial element, prioritized over the requests for identity disclosure from recipients and offspring. Demographic parameters exhibit a strong and precise effects on participants' perceptions.

Extended families? Contact expectations and experiences of egg donors donating to previously unknown recipients

In New Zealand egg donation is identity-release, and donors may be known to recipients, e.g. family members/friends, or previously unknown e.g. clinic-recruited or sourced through advertising. In the case of unknown donors, New Zealand practice allows donors and recipients to meet face-to-face prior to donation in a joint counselling meeting. While contact details may not necessarily be exchanged in counselling, information-exchange and contact expectations are usually addressed. In previous papers, we explored donors' motivations and experiences of donation. In this paper, we explore donors' ideas around their role in relation to the donor-conceived person (DCP) and their expectations and experiences of information-exchange and contact. While donors did not see themselves as parents and were aware of appropriate boundaries, they described a sense of ongoing connection to DCP, often framing this in extended family terms. They desired to be kept informed about DCP, considered themselves 'on standby' for information requests or in-person contact and valued the opportunity for connection between their children and DCP. Donors were, however, cognisant of the limits to their ability to ensure information-exchange and contact and sometimes struggled with their perceived disempowered position. Meeting prior to donation may both clarify and reinforce expectations of information-exchange and contact.

We want to feel valued: eggs donors' experiences of donation

Egg donation in New Zealand is identity-release, with donor-conceived individuals having the right to access donors' identifying information at the age of 18. It also allows donors and previously unknown recipients to meet prior to donation. Further, donation is altruistic, although reimbursement of costs is possible. In our previous paper we explored the motivations of 21 egg donors in this context and reported that they are motivated to donate as an act of personal gift-giving to recipients who may become known to them through donation, and that they do not want to be compensated for this financially. In this paper, drawing on in-depth interviews, we report on donors' experiences of the donation process and subsequent to donation. Donors understood their donations to be a significant act, both for the recipients and their families, but also for themselves, particularly given the multiple sacrifices which they willingly made. Donors wished for their gift and their role to be valued and acknowledged through being appreciated, informed, involved and supported by recipients and clinics before, during and after their donations. These findings have implications for clinical practice and care, offering insight into how best to support donors prior and subsequent to donation.

Who's your daddy? An ethical argument for disclosure to donor conceived children

To our knowledge, there have been few discussions in the andrology literature regarding the ethics of disclosure to donor conceived children. Our goal in this paper is to summarize the main reasons in favor of disclosure to engender more conversations about the ethics of donor conception in andrology circles. Specifically, we argue (1) transparency regarding gamete donation upholds the ethical principle of beneficence by improving the psychological health of donor conceived children; and (2) based on the ethical principle of autonomy, donor conceived children should have the right to know their donor status.

The Child's Right to Know Versus the Parents' Right Not to Tell: The Attitudes of Couples Undergoing Fertility Treatments Towards Identity-Release Gamete Donation

Background

In Brazil, donor anonymity is mandatory; however, the tendency of Brazilians towards the practice is unknown. In this study, an attempt was made to investigate whether couples undergoing assisted reproductive technology (ART) have a different perception of anonymous versus identity-release gamete donation than a target population in Brazil.

Methods

This cross-sectional study was performed from September 1, 2020 to December 15, 2020. For that purpose, surveys through online platforms were conducted, including either patients undergoing ART (ART-group, n=400) or subjects interested in the theme (interested-group, n=100) randomized by age at a 1:4 ratio. The survey collected information on the participants' attitudes towards anonymity of gamete donors, and answers were compared between the groups.

Results

Most participants stated that the relationship between children and their parents would be affected by the child's knowledge of the origin of its conception. Most participants in the ART-group believed that the gamete donor's identity should not be revealed to the child, while only half of the interested-group stated the same. Most of the participants stated that "the donor's identity should be revealed if the child questions its biological origin". "From birth" was the second most common response, while "when the child turns 18 years old" and "sometime during teenage years" were less common answers.

Conclusion

The attitudes of ART patients about anonymity are conservative, with most participants believing that family relationships may be affected if the child is aware of the origin of his/her conception. These patients also believe that the identity of the gamete donor should not be revealed to the child.

Sperm donor attitudes and experiences with direct-to-consumer genetic testing

Objective

To identify factors influencing sperm donor willingness to participate in direct-to-consumer genetic testing, comfort with sharing genetically identifiable data in commercial genetic testing databases, and likelihood to donate sperm again.

Design

Cross-sectional online anonymous survey.

Setting

Multicenter, 2 large American sperm banks from July 1, 2020 to July10, 2021.

Patients

Sperm donors from 1980 to 2020.

Interventions

None.

Main outcome measures

Associations between donor demographic characteristics, donation history, and attitudes toward direct-to-consumer genetic testing.

Results

A total of 396 donors completed the survey. Most donations (61.5%) occurred from 2010 to 2020, and 34.3% were nonidentified donations. Nonidentified donors were less comfortable with their genetic data being shared than open-identity donors (25.4% vs. 43.8%) and were less likely than open-identity donors to donate sperm again (43.3% vs. 72.1%). Donors who donated after the inception of direct-to-consumer genetic testing in 2007 were less likely to participate in commercial genetic testing than those who donated before 2007 (25.8% vs. 37.1%). Most donors (87.4%) have disclosed their donation(s) to current partners, but fewer have disclosed them to their families (56.6%) or children (30.5%). Of the donors who had been contacted by donor-conceived persons, 79.5% were identified via direct-to-consumer genetic testing. Overall, 61.1% of donors would donate again regardless of direct-to-consumer genetic testing.

Conclusions

Direct-to-consumer genetic testing is playing a dynamic role in sperm donor identification, but donors seem willing to donate again. Implication counseling regarding future linkage and contact from donor-conceived persons needs to be standardized for potential donors before donation.

Donation of the body and its parts in the construction of parenthood

The developments of science and technology make possible today unprecedented exchanges of body parts by multiplying the figures and links that intervene in the process of building parenthood and generating significant ethical and judicial controversies. Body donation in the procreative field constitutes an anthropological and social phenomenon of increasing attention, which contributes to one of the most intimate and profound aspirations of the human being and which requires a careful evaluation of the various interests involved and a thorough reflection on the statute and characteristics of the parental bond. The interest of the child, the dignity of women and the quality of human relations are the parameters of this analysis and, at the same time, the perimeter of the judgment. However, the approach to these issues is complicated not only by the extreme heterogeneity of legislation but also by suspicions and prejudices that hinder reflection appropriate to the complexity of the issues involved. Investigate the reasons for the choice of donation, the criticalities, and possible drifts, without closing in their subjective value horizon, is an unavoidable prerequisite for a comparison with the new social realities of the family that respects the fundamental rights of the person.

Oocyte Donation: Three Perspectives

Background: A number of important problems remain unresolved in the field of assisted reproductive technologies (ART) using germ cells from a single donor. This study aimed to assess attitudes about the use of sex gamete donation in ART in different social groups including medical workers, oocyte recipients, and oocyte donors. Methods: To achieve this goal, we surveyed 286 participants from seven countries. Of them, 190 were medical workers from ART clinics (respondents from seven countries), 45 were oocyte recipients (Kazakhstan), and 51 were oocyte donors (Kazakhstan). Results: A survey of the three groups showed that issues related to donor health were most common in the donor selection process based on patient and doctor distrust of the health care system. The main motive for oocyte donation was financial compensation, which draws attention to the social disadvantage of the donor population. Medical workers with more than 5 years of work experience (79.7%) supported the use of programs tracking donor sex gametes and limiting the use of oocyte donors. Conclusions: The willingness and consent of the surveyed medical workers and oocyte recipients to use the donor material and create a unified registry of donor sex gametes demonstrates the importance of this issue.

Psycho-social experience of oocyte recipient women: a qualitative study

Background

Although associated with many successes, oocyte donation can lead to numerous psychological challenges in recipient women. The identification of these challenges during the treatment process is crucial to improve recipient mental health. Thus, the aim of this study was to gain an understanding of the experiences of oocyte recipient women.

Methods

This research was conducted using a qualitative approach and inductive content analysis method. The data collection tool was in-depth interviews. Twenty women with the experience of receiving donated oocyte were selected and entered the study using purposive sampling method and considering the maximum variation.

Results

Three main categories of psychological challenges were extracted from patient interviews, specifically, distressing psychologic symptoms, social stigmatization, and negative coping mechanisms. The category of distressing psychologic symptoms was shaped based on the subcategories of self-esteem destruction, anxiety and stress, depression and spiritual discouragement. The category of social stigmatization included the subcategories of concern about disclosure, judgment of others, and conflict with religious teachings. And the category of negative coping mechanisms was formed based on the subcategories of aggression and denial.

Conclusion

The results indicated that the process of treatment with donated oocyte is followed by the experiences of distressing psychologic symptoms, social stigmatization, and negative coping mechanisms in recipient women. As such, paying attention to the socio-cultural factors which affect this process seems necessary to maintain the mental health of these women.

Plain English summary

Although associated with many successes, oocyte donation can lead to numerous psychological challenges in recipient women. The aim of this study was to gain an understanding of the experiences of oocyte recipient women. This research was conducted using a qualitative approach and inductive content analysis method. The data collection tool was in-depth interviews. Twenty women with the experience of receiving donated oocyte were selected and entered the study using purposive sampling method and considering the maximum variation. Three main categories of psychological challenges were extracted from patient interviews, specifically, distressing psychologic symptoms, social stigmatization, and negative coping mechanisms. The category of distressing psychologic symptoms was shaped based on the subcategories of self-esteem destruction, anxiety and stress, depression and spiritual discouragement. The category of social stigmatization included the subcategories of concern about disclosure, judgment of others, and conflict with religious teachings. And the category of negative coping mechanisms was formed based on the subcategories of aggression and denial. The results indicated that the process of treatment with donated oocyte is followed by experience of distressing psychologic symptoms, social stigmatization, and negative coping mechanisms in recipient women. As such, paying attention to the socio-cultural factors which affect this process seems necessary to maintain the mental health of these women.

Motivations for egg donation to previously unknown recipients: donation as a personal, relational act of giving

Egg donation has becoming increasingly common however there is a shortage of donors in many countries, including New Zealand. Research regarding motivations to donate in the context of New Zealand's open-identity and altruistic donation policy and practice is, thus far, limited. This in-depth qualitative study comprised interviews with 21 women to examine their motivations in donating to recipients previously unknown to them. Donors valued parenthood highly and had become aware of the fertility struggles of other women through their own experiences, those of friends or family, or through online personal accounts or advertising. The ability to select recipients and build a comprehensive picture of them, such as through reading recipient profiles or meeting them in person, as is possible in New Zealand, deepened their identification with recipients and thus their empathy and desire to help. They resisted commercial models, positioning themselves as by nature altruistic and regarding their donations as expressions of solidarity and acts of personal gift-giving to specific others who became known to them through donation. Donation was interpreted as a socially relational process, setting up expectations around relationships and ongoing connection. Such understandings have implications for recruitment as well as ongoing experiences and support needs.

Fertility Counseling in Survivors of Cancer in Childhood and Adolescence: Time for a Reappraisal?

Genetic predisposition could have an important role in the pathogenesis of cancers in children and adolescents. A recent study by our group showed that, among female survivors of cancers in childhood and adolescence, the proportion of cases involving a possible genetic predisposition was sizable (at least one in five). Our sample is too small to be representative of the general population, but it gave us an opportunity to reappraise this issue. Women with a genetic predisposition can transmit the risk of cancer to their offspring, and their awareness of this may influence their reproductive and fertility preservation choices. In our experience, a predisposition to cancer receives little attention in the fertility counseling and decision-making process unless a patient already has a definitive molecular diagnosis of a hereditary cancer syndrome. We feel it is essential to empower women on this issue, particularly as there are ways to overcome the problem, including preimplantation genetic testing (PGT-M) in definitively diagnosed cases, egg donation and adoption. In the context of fertility counseling for survivors of cancer in childhood and adolescence who have reached adulthood, the risk of transmitting a predisposition to cancer should be discussed with patients, if relevant and desired.

Fertility preservation in childhood and adolescent female tumor survivors

OBJECTIVE

To assess the proportion of female childhood and adolescent tumor survivors who could benefit from oocyte cryopreservation.

DESIGN

Case series of female childhood and adolescent tumor survivors referred for fertility counseling.

SETTING

A referral cancer center and an infertility unit of an academic hospital.

PATIENT(S)

Young female childhood and adolescent tumor survivors who received gonadotoxic treatments.

INTERVENTION(S)

Patients were prescribed tests of ovarian reserve and a personalized counseling was given. Oocyte cryopreservation was considered in subjects aged ≥18 years who were diagnosed with diminished ovarian reserve (DOR) (antimüllerian hormone level <2 ng/mL or total antral follicle count ≤10).

MAIN OUTCOME MEASURE(S)

Rate of women with DOR who stored their oocytes.

RESULT(S)

Ninety out of 126 evaluated women completed the assessments. We documented preserved ovarian reserve, DOR, and premature ovarian insufficiency in 36 (40%), 35 (39%), and 19 (21%) cases, respectively. Overall, 13 subjects with DOR were eligible for oocyte cryostorage, of whom 9 (69%) underwent the procedure. Considering the whole cohort of evaluated young women (n = 90), the rate of those who had egg freezing was 10%. Finally, nine women started seeking pregnancy after the counseling (six with DOR), and seven of them became pregnant. When the data were analyzed separately according to most gonadotoxic treatments, considerable differences emerged but the evidence did not support the idea that counseling should be restricted to particular subgroups of women.

CONCLUSION(S)

Ovarian reserve impairment is common in female childhood and adolescent tumor survivors. Postcancer oocyte cryopreservation may be part of the armamentarium of fertility preservation options.

Positioning the donor in a new landscape-mothers' and fathers' experiences as their adult children obtained information about the identity-release sperm donor

STUDY QUESTION

How do heterosexual parents experience identity-release donation when adult children have obtained information about their sperm donor?

SUMMARY ANSWER

Adult offspring's receipt of identifying information about the sperm donor challenged the fathers' role as a parent, which was reflected in how parents positioned the donor in relation to the family.

WHAT IS KNOWN ALREADY

An increasing number of countries provide access to treatment with identity-release or 'open-identity' donors. However, there is limited knowledge about how parents experience and manage the situation when adult offspring obtain identifying information about the donor and may even establish contact with him.

STUDY DESIGN, SIZE, DURATION

This qualitative interview study included 23 parents whose offspring had obtained information about their sperm donor. Interviews were conducted from October 2018 to January 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A purposive sample of parents (15 mothers and 8 fathers) was recruited via adult offspring, who had requested identifying donor information at five Swedish University hospitals. All participating parents were part of a heterosexual couple who had conceived with sperm from an identity-release donor. Individual semi-structured interviews were conducted face-to face or via telephone, and transcribed audio recordings were analyzed using reflexive thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The parents expressed diverse experiences related to their parenthood and the presence of the donor after offspring had obtained information about him; these were described in two themes. The theme 'Navigating (in)visible markers of parenthood' describes parenthood as embedded with dichotomous meanings of nature and nurture that parents navigated in relation to social approval. The theme 'Positioning the donor in a new landscape' describes how parents managed the presence of the donor by positioning him at a distance or acknowledging him as a person or even as part of the family, while some struggled to position him, giving rise to ambivalent feelings. The absence of genetic connectedness challenged the father's role as parent, which was reflected in parents' positioning of the donor.

LIMITATIONS, REASONS FOR CAUTION

The study was performed within the context of the Swedish legislation on identity-release donation and is based on experiences of heterosexual couples who had used sperm donation and had informed their offspring about their donor conception. This, together with the fact that parents' accounts were predominantly represented by mothers, must be taken into consideration regarding transferability to other populations.

WIDER IMPLICATIONS OF THE FINDINGS

Negotiations of social and genetic parenthood are still present among parents many years after treatment and may resurface when adult offspring obtain the donor's identity. Access of the adult offspring to identifying information about the donor may have unexpected consequences for family relations, including expanding the family to include the donor. Challenges related to male infertility and family dynamics indicate that parents should have access to counseling and support to manage family life with varying genetic linkage within and outside the family unit.

STUDY FUNDING/COMPETING INTEREST(S)

Financial support was from The Swedish Research Council (Grant 2013-2712). There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Life Finds a Way: Young Adults With Lesbian Mothers Reflect on Their Childhood Prior to Legal Recognition of Same-Sex Parents in Sweden

The strapline "life finds a way," from the classic movie Jurassic Park, referred to how the all-female dinosaurs in a theme park had been able to reproduce, despite the laws of nature. Similarly, the participants in the present study described how their lesbian mothers had shown that "life finds a way," when having children and forming a family, prior to the legal recognition of same-sex parents in Sweden. The study draws on interviews with eight young Swedish adults, aged 17-30 (average age 25). They had been raised by lesbian couples but were born prior to the legal recognition of same-sex parenthood. Prior to a legal change in 2003, a same-sex couple could not share legal parenthood. Further, female couples were excluded from Swedish assisted reproduction programs until 2005. The interviews have been analyzed thematically, and the article presents the results in four themes. The first theme, circumvent, oppose, or adapt to legal obstacles, shows the participants' reflections on how their parents navigated legal obstacles in order to have children and to live together as a family. The second theme, legal obstacles do not affect everyday life, depicts a common experience of how a lack of legal recognition seldom mattered to the participants during their childhood. Rather, they explained how their parents had been able to form parenthood and close relations without legal recognition. In contrast, the third theme describes occasions when legal parenthood matters. This theme highlights occasions when the lack of legal parenthood was problematic or devastating for the participants, such as when parents divorced, or one parent died. The final theme, the meaning of legal parents in adulthood, explores the participants' reflections on the meaning and impact of legal ties (or lack of legal ties) between themselves as young adults and their parents. The findings are discussed in relation to previous research on children and young adults with same-sex parents.