To tell or not to tell: the decision-making process of egg-donation parents

Perceptions of Fertility Physicians Treating Women Undergoing IVF Using an Egg Donation

In the course of their work, medical teams are routinely exposed to difficult and stressful situations. The few studies in the literature that have examined physicians’ perceptions and responses to such situations have focused primarily on the fields of emergency medicine and chronic and terminal illness. However, the field of fertility medicine can also evoke complex feelings among physicians. The present qualitative study examined the perceptions of fertility physicians treating women undergoing egg donation. Semi-structured in-depth interviews were conducted with 20 fertility physicians, and a categorical analysis was performed. The main category to emerge was the physicians’ perception of egg donation and its implications. Two prominent themes were identified within this category: doctor–patient communication surrounding egg donation and how the idea was presented to the patient; and doctors’ perception of the implications of egg donation, including maternal identity, the relationship between mother and infant, and the mother’s sense of the child’s identity. This is the first study to consider the response to fertility treatments, a contemporary and sensitive topic, from the perspective of the physicians. The findings can contribute to physicians’ understanding of themselves and can help to devise ways to assist them in managing their emotional responses to their work for the benefit of both themselves and their patients.

"I want us to be a normal family": Toward an understanding of the functions of anonymity among U.S. oocyte donors and recipients

BACKGROUND

Anonymity remains the more common practice in gamete donations, but legislation prohibiting anonymity with a goal of protecting donor-conceived children's right to know their genetic origins is becoming more common. However, given the dearth of research investigating the function of anonymity for donors and recipients, it is unclear whether these policies will accomplish their goals. The aim of this study was to explore experiences with anonymity among oocyte donors and recipients who participated in an anonymous donor oocyte program and to understand the ways in which anonymity functions for them.

METHODS

Semistructured interviews were conducted with 50 women: 28 oocyte donors and 22 recipients who were recruited from an academic center for reproductive medicine in the United States.

RESULTS

Donors and recipients view anonymity both as a mechanism to protect the interests of all parties (recipients, donors, and donor-conceived children) and as a point of conflict. Specifically, three key areas were identified where both donors and recipients saw anonymity as having an important role: relieving anxieties about family structures and obligations; protecting their interests and those of donor-conceived children (while acknowledging where interests conflict); and managing the future.

CONCLUSION

As gamete donation increasingly moves away from the practice of anonymity, examining why anonymity matters to stakeholders will be helpful in devising strategies to successfully implement identity-release options.

Disclosure of donor conception in the era of non-anonymity: safeguarding and promoting the interests of donor-conceived individuals?

This article responds to a debate article published in Human Reproduction earlier this year. In that article, the authors suggested that parents should be encouraged to disclose the use of donor gametes to their children given rapid and widespread advances in genetic testing and sequencing. However, there is an urgent need to engage with the assertion that in this context, telling children about their donor conception both safeguards and promotes their interests, particularly if such disclosure is motivated by parents' anxieties about accidental discovery. Disclosure that is motivated by the notion of non-anonymity may also encourage parents to share misinformation about donors and encourage their children to have unrealistic expectations. Fertility professionals must remain mindful of these outcomes when discussing disclosure and the future implications of increasing access to genetic information with both prospective and current parents. It is strongly advised that future discussions about the end of donor anonymity are not conflated with the debate on disclosure.

Intra-Family Gamete Donation: A Solution to Concerns Regarding Gamete Donation in China?

Gamete donation from third parties is controversial in China as it severs blood ties, which are considered of utmost importance in Confucian tradition. In recent years, infertile couples are increasingly demonstrating a preference for the use of gametes donated by family members to conceive children-known as "intra-family gamete donation." The main advantage of intra-family gamete donation is that it maintains blood ties between children and both parents. To date there is no practice of intra-family gamete donation in China. In this paper, we investigate intra-family adoption in China in order to illustrate that intra-family gamete donation is consistent with Confucian tradition regarding the importance of maintaining blood ties within the family. There are several specific ethical issues raised by intra-family gamete donation. It may, for example, result in consanguinity and the semblance of incest, lead to confused family relationships, and raise concerns about possible coercion of familial donors. Confucian tradition provides a new approach to understand and deal with these ethical issues in a way that Western tradition does not. As a result, we suggest intra-family gamete donation could be an acceptable solution to the problem of infertility in China. However, further discussion and open debates on the ethical issues raised by intra-family gamete donation are needed in China.

[Psychosocial factors in reproductive medicine]

INTRODUCTION

Since the development of assisted reproduction technology in the 1970s, assisted reproduction has become increasingly used by couples for various reasons. Concurrently, the diagnostic possibilities regarding the health of the unborn child have been elaborated.

METHODS/RESULTS

The present literature review describes and discusses the possibilities of assisted reproduction (in-vitro fertilization (IVF), intracytoplasmic sperm injection ICSI, cryopreservation, conception of children with the help of a third person) with respect to their psychosocial meaning for those affected and for the children conceived in this manner. The psychological strain pairs experience in the context of prenatal diagnostics and the resulting decisions are illustrated by a case study.

CONCLUSIONS

The continued progression in the possibilities and resulting conflicts and decision- making processes in reproductive medicine confronts clinicians and psychosomatic/psychotherapeutic practitioners with many new challenges. In conclusion clinical recommendations for the psychosocial counseling of couples are given.

It takes two to tango: information-sharing with offspring among heterosexual parents following identity-release sperm donation

STUDY QUESTION

How do heterosexual parents reason about and experience information-sharing with offspring following identity-release sperm donation?

SUMMARY ANSWER

Sharing information about using donor-conception with offspring is a complex process at several levels, with the parent's personal beliefs and the child's responses serving as driving or impeding forces for the information-sharing process.

WHAT IS KNOWN ALREADY

The overall view of disclosure in gamete donation has shifted from secrecy to openness, but there is still uncertainty among parents concerning how and when to tell the child about his/her genetic origin. Most research on donor-conceived families has focused on donation treatment under anonymous or known circumstances, and there is a lack of studies in settings with identity-release donations.

STUDY DESIGN, SIZE, DURATION

A qualitative interview study among 30 parents following identity-release sperm donation treatment. Interviews were conducted from February 2014 to March 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The present study is part of the prospective longitudinal Swedish Study on Gamete Donation (SSGD), including all fertility clinics performing gamete donation in Sweden. A sample of participants in the SSGD, consisting of heterosexual parents with children aged 7–8 years following identity-release sperm donation, participated in individual semi-structured interviews.

MAIN RESULTS AND THE ROLE OF CHANCE

The analysis revealed one main theme: information-sharing is a process, with three subthemes; (i) the parent as process manager, (ii) the child as force or friction and (iii) being in the process. The first two subthemes were viewed as being linked together and their content served as driving or impeding forces in the information-sharing process.

LIMITATIONS, REASONS FOR CAUTION

The fact that the study was performed within the context of the Swedish legislation on identity-release donation must be taken into consideration as regards transferability to other populations, as this may affect parents' reasoning concerning their information-sharing with the child.

WIDER IMPLICATIONS OF THE FINDINGS

The present findings highlight the role of the donor-conceived child in the information-sharing process and may contribute to develop counselling that increases parents' confidence in handling children's reactions to information about their genetic origin.

STUDY FUNDING/COMPETING INTEREST(S)

Financial support from The Swedish Research Council, The Family Planning Fund in Uppsala and Ferring Pharmaceuticals. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Gendering gametes: The unequal contributions of sperm and egg donors

This paper compares three groups of gestational mothers who relied on gametes from donors they did not know. The three groups are women who have conceived with donor sperm and their own eggs, women who have conceived with donor eggs and a partner's sperm, and women who have conceived with embryos composed of both donor eggs and donor sperm. The paper explores three issues. First, it considers whether intending parents select sperm and egg donors for different attributes both when they are chosen as the only donor and when they are chosen as donors contributing to an entire embryo. Second, it examines how women imagine the donor. Finally, it looks at how women conceptualize the donor as an individual who contributes to their child's characteristics. Two significant findings emerged in this analysis of survey data. First, the data show that gametes are gendered with different attributes both when those gametes are separate and even more so when seen as complementary parts of a whole. Second, the data show that women minimize the impact of the egg donor (both when a sole contribution and especially when part of the complementary whole) and thus ignore the influence or impact of the egg donor relative to how they make sense of the influence or impact of the sperm donor. The data for this study comes from an online survey developed by the authors.

Assisted reproduction for postmenopausal women

With increasing longevity, an ageing population and advances in assisted reproductive technologies (ART), a greater number of women are deciding to have a child and become a mother in their later years. With this social and demographic change, an important social and ethical debate has emerged over whether single and/or married postmenopausal women should have access to ARTs. The aim of this paper is to address this question and review critically the arguments that have been advanced to support or oppose the use of ART by older women. The arguments presented consider the consequences for the individual, the family and wider society. They cover the potential physical and emotional harm to the older woman, the possible impact on the welfare and wellbeing of the future child, and the impact on the norms, values, customs and traditions of society. After reviewing the evidence, and weighing the opposing arguments, this paper concludes that there is no moral justification for a restriction on the use of ART by postmenopausal women. Allowing access to ART for postmenopausal women is an extension of reproductive autonomy and procreative rights in an age where the promotion of agency, autonomy, individual choice and human rights is paramount.

Conceptualising a child-centric paradigm : do we have freedom of choice in donor conception reproduction?

Since its inception, donor conception practices have been a reproductive choice for the infertile. Past and current practices have the potential to cause significant and lifelong harm to the offspring through loss of kinship, heritage, identity, and family health history, and possibly through introducing physical problems. Legislation and regulation in Australia that specifies that the welfare of the child born as a consequence of donor conception is paramount may therefore be in conflict with the outcomes. Altering the paradigm to a child-centric model, however, impinges on reproductive choice and rights of adults involved in the process. With some lobby groups pushing for increased reproductive choice while others emphasise offspring rights there is a dichotomy of interests that society and legislators need to address. Concepts pertaining to a shift toward a child-centric paradigm are discussed.

Choreographies of sperm donations: dilemmas of intimacy in lesbian couple donor conception

Assisted conception involving donor insemination challenges cultural idioms of parenthood and family; there is now a growing body of work exploring how women and couples negotiate becoming a family in this way. But sperm donation also raises questions on the more intimate levels of sex, sexuality and sexual bodies, and these have received little sustained attention in the literature. Lesbian couples in the U.K. increasingly negotiate access to medicalised donor insemination, but many also conceive in informal arrangements with donors where they themselves negotiate proximity and contact with donors when retrieving donor sperm. I explore in this paper how lesbian couples manage and perceive sperm donations, how they seek to negotiate their intimate, sexual and bodily overtones, and how the medical and non-medical settings enable them to do this in different ways. I draw on empirical data from an interview study conducted from 2006 to 2009 in England and Wales comprising 25 lesbian couples. I suggest that sperm donation raises dilemmas of intimacy for lesbian couples, and that couples try to resolve such dilemmas by carefully and intentionally choreographing donation events through managing patterns of movement and action. The different institutional, medical and regulatory frameworks governing clinical and non-clinical sperm donation shape that management in significant and different ways. I argue that sperm donation choreographies enable couples to negotiate the private, sexual and intimate tensions surrounding sperm donations, and also the subjectivity of the sperm donor.

Secrecy, disclosure and everything in-between: decisions of parents of children conceived by donor insemination, egg donation and surrogacy

This study examined families where children lack a genetic and/or gestational link with their parents. A total of 101 families (36 donor insemination families, 32 egg donation families and 33 surrogacy families) were interviewed when the child was aged 7 years. Despite a shift in professional attitudes towards openness, about half of the children conceived by egg donation and nearly three-quarters of those conceived by donor insemination remained unaware that the person they know as their mother or father is not, in fact, their genetic parent. By contrast, almost all the surrogacy parents had told their child how they were born. A majority of parents who planned never to tell their child about their conception had told at least one other person. However, qualitative data indicated that to categorize families as 'secret' or 'open' is inadequate. In fact many parents engage in 'layers' of disclosure about their child's conception, both with their child and with family and friends.

Two decades after legislation on identifiable donors in Sweden: are recipient couples ready to be open about using gamete donation?

BACKGROUND Two decades after the introduction of Swedish legislation that allows children born as a result of gamete donation access to identifying information about the donor, a nationwide multicentre study on the psychosocial consequences of this legislation for recipients and donors of gametes was initiated in 2005. The aim of the present study was to investigate recipient couples' attitudes and behaviour regarding disclosure to offspring and others, attitudes towards genetic parenthood and perceptions of information regarding parenthood after donation. METHODS The present study is part of the prospective longitudinal 'Swedish study on gamete donation', including all fertility clinics performing donation treatment in Sweden. A consecutive cohort of 152 heterosexual recipient couples of donated oocytes (72% response) and 127 heterosexual recipient couples of donated sperm (81% response) accepted participation in the study. In connection with the donation treatment, male and female participants individually completed two questionnaires with study-specific instruments concerning disclosure, genetic parenthood and informational aspects. RESULTS About 90% of participants (in couples receiving anonymous donated gametes) supported disclosure and openness to the offspring concerning his/her genetic origin. Only 6% of all participants had not told other people about their donation treatment. Between 26 and 40% of participants wanted additional information/support about parenthood following donation treatment. CONCLUSIONS Two decades after the Swedish legislation of identifiable gamete donors, recipient couples of anonymously donated sperm and oocytes are relatively open about their treatment and support disclosure to offspring. Recipient couples may benefit from more information and support regarding parenthood after gamete donation. Further studies are required to follow-up on the future parents' actual disclosure behaviour directed to offspring.

"Public" perceptions of gamete donation: a research review

This paper reviews the literature on "public" perceptions of the practice of gamete (egg and sperm) donation in the treatment of infertility. Despite regular "consultation" exercises in the UK on the manner in which infertility treatments should be regulated, there is little sense of how a range of public groups respond to developments in this area. The key themes from thirty-three articles, chapters and reports are discussed. The review reveals the limited nature of our current knowledge of public understandings of and attitudes towards gamete donation as a form of infertility treatment which has been readily available and widely practiced for many years. The review is critical of the methodological and epistemological basis of much of the work in this area and argues that there is a strong case for social scientific research to attempt to capture the perceptions of a wider range of people who are rarely included in formal public consultations and often similarly excluded from research studies.

Prospective parents' intentions regarding disclosure following the removal of donor anonymity

This short survey of UK infertility counsellors was designed to determine whether the removal of donor anonymity resulted in noticeable changes in prospective parents' stated intentions regarding disclosure of their origins to any children conceived through donor conception. Members of the British Infertility Counselling Association working in Human Fertilisation and Embryology Authority (HFEA) -- licensed centres, before and after the legal changes, were sent a short questionnaire that included space for free comments (take-up: 62%). Three-quarters reported changes. Of these, two-thirds said prospective parents were more likely to say they would disclose, while less than a tenth said prospective parents were less likely do so. Where no changes were noted, this was primarily because the majority of prospective parents had stated their intention to be open even prior to the legal changes. Possible influences on intentions included: the culture within the centre, moves towards openness within the wider society, and parents' lack of confidence regarding how to go about disclosure. Follow-up studies are needed to improve understanding of whether influences on decision making carry through to patterns of actual disclosure; whether involvement in counselling affects outcomes; and whether access to professional assistance at the time of planned disclosure is helpful.

How parents whose children have been conceived with donor gametes make their disclosure decision: contexts, influences, and couple dynamics

OBJECTIVE

To describe parents' disclosure decision-making process.

DESIGN

In-depth ethnographic interviews.

SETTING

Participants were recruited from 11 medical infertility practices and 1 sperm bank in Northern California.

PATIENT(S)

One hundred forty-one married couples who had conceived a child using donor gametes (62 with donor sperm, 79 with donor oocytes).

INTERVENTION(S)

Husbands and wives were interviewed together and separately.

MAIN OUTCOME MEASURE(S)

Thematic analysis of interview transcripts.

RESULT(S)

Ninety-five percent of couples came to a united disclosure decision, some "intuitively," but most after discussions influenced by the couples' local sociopolitical environment, professional opinion, counseling, religious and cultural background, family relationships, and individual personal, psychological, and ethical beliefs. Couples who were not initially in agreement ultimately came to a decision after one partner deferred to the wishes or opinions of the other. Deferral could reflect the result of a prior agreement, one partner's recognition of the other's experiential or emotional expertise, or direct persuasion. In disclosing couples, men frequently deferred to their wives, whereas, in nondisclosing couples, women always deferred to their husbands.

CONCLUSION(S)

Although the majority of couples were in initial agreement about disclosure, for many the disclosure decision was a complex, negotiated process reflecting a wide range of influences and contexts.

Pregnant, donor oocyte recipient women describe their lived experience of establishing the "family lexicon"

OBJECTIVE

To describe the lived experience of pregnant women who used donor oocytes for conception.

DESIGN

Qualitative, using a descriptive phenomenologic approach.

SETTING

Interviews were completed at a location and setting selected by the participant. Of the 16 interviews, 13 were conducted at the participant's home, 1 was conducted at a private office, and 2 were conducted by telephone.

PARTICIPANTS

Eight women, between the ages of 33 and 46 years, were recruited at a large urban infertility center. The women were between 9 and 23 gestational weeks pregnant at the time of data collection. Each of the women participated in two open-ended, in-depth, audiotaped interviews and answered a demographic questionnaire.

RESULTS

Four themes emerged from the women's description of their experience, which were (a) acknowledging the desire for motherhood, (b) accepting and coming to terms with donor oocytes as a way to achieve motherhood, (c) navigating an intense period of decision making, and (d) living with the lasting legacy of achieving motherhood through oocyte donation.

CONCLUSION

Clinical practice can be improved by incorporating recognition, support, and communication of the experience to women contemplating or undergoing donor oocyte treatment.

Strategies for disclosure: how parents approach telling their children that they were conceived with donor gametes

OBJECTIVE

To describe how parents envision, plan, and enact disclosing to their children that they were conceived with donor gametes.

DESIGN

In-depth ethnographic interviews.

SETTING

Participants were recruited from 11 medical infertility practices and 1 sperm bank in Northern California.

PATIENT(S)

A total of 141 married couples who had conceived a child using donor gametes (62 with donor sperm and 79 with donor oocytes).

INTERVENTION(S)

Husbands and wives were interviewed together and separately.

MAIN OUTCOME MEASURE(S)

Thematic analysis of interview transcripts.

RESULT(S)

Disclosing parents predominantly subscribed to one of two disclosure strategies: the conviction that early disclosure is of paramount importance so that the child "always knows," or the belief that later disclosure is preferable after family routines have been established and the child has the maturity to understand biologic concepts and has developed a sense of discretion. No parent regretted disclosing, and many expressed relief.

CONCLUSION(S)

Parents choosing early disclosure were more at ease with the disclosure process, whereas parents choosing later disclosure reported greater uncertainty about how and when to disclose. Parents wished for more peer and/or professional support and guidance to assist them with disclosure, not only initially but continuing long after their children were born.

Disclosure decisions among pregnant women who received donor oocytes: a phenomenological study

OBJECTIVE

To investigate the controversy surrounding disclosure among donor oocyte recipients. This controversy is escalating worldwide, yet little research has sought to understand the disclosure experience of pregnant, donor oocyte recipient women. This study aims to provide an in-depth description of the disclosure experience, and identify factors that were significant to recipient women which influenced their reasoning as they formulated disclosure decisions.

DESIGN

Qualitative, naturalistic design, using a phenomenological approach.

SETTING

The home or private office of the recipient woman.

PATIENT(S)

Donor oocyte recipient women between 9-23 weeks of gestation.

RESULT(S)

Disclosure decisions were influenced by multiple factors emerging from the women's values and beliefs and their social and cultural environment. Values and beliefs consisted of the right to know and the duty to protect. Social and cultural factors included social support, culture of the family, evolution of the social process, and personal testimonials. Women's age and selection of donor type were interrelated with disclosure decisions.

CONCLUSION(S)

Disclosing women voiced the right of the child to know, and perceived social and cultural factors as conducive to disclosure. Nondisclosing and undecided women emphasized protecting normative relationships, perceived a social stigma, and were unable to identify a benefit to disclosing. Women's age and choice of oocyte donor should be considered when counseling recipient women.

Egg donation parents and their children: follow-up at age 12 years

OBJECTIVE

To assess the quality of parenting and psychological adjustment of egg donation families as the child approaches adolescence in comparison with donor insemination (DI) and IVF families.

DESIGN

A study of 17 egg donation families, 35 DI families, and 34 IVF families with a 12-year-old child. Standardized interview and questionnaire measures were administered to mothers and children.

SETTING

Follow-up of families recruited from three assisted conception units in the United Kingdom.

PATIENT(S)

Mothers and their 12-year-old children conceived through egg donation, DI, and IVF.

INTERVENTION(S)

Mothers and children were interviewed and administered questionnaires.

MAIN OUTCOME MEASURE(S)

Parents' marital and psychological state, quality of parent-child relationships, father's contribution to parenting, and children's socioemotional development.

RESULT(S)

No differences were found between the egg donation and IVF families. The differences between egg donation and DI families reflected lower levels of sensitive responding of egg donation mothers toward their children compared with DI mothers. Donor insemination mothers were more likely to be emotionally over-involved with their child than egg donation mothers. The egg donation children were well adjusted in terms of their social and emotional development.

CONCLUSION(S)

The findings are discussed in relation to the different pattern of genetic relationships between egg donation and DI families and the secrecy surrounding the use of donated gametes to conceive a child.

Parenting infants conceived by gamete donation

In recent years, concerns have been raised regarding the potentially negative consequences of gamete donation for parent-child relationships. Findings are presented of a study of families with an infant conceived by gamete donation. Fifty donor insemination families and 51 egg donation families were compared with 80 natural conception families on standardized interview and questionnaire measures of the psychological well-being of the parents, the quality of parent-child relationships, and infant temperament. The differences that were identified indicated more positive parent-child relationships among the gamete donation than the natural conception parents, accompanied by greater emotional involvement with the child. Comparisons were also carried out between the donor insemination and the egg donation parents on their experiences of gamete donation. In contrast to the findings of earlier investigations, the donor insemination and egg donation parents appeared to be more open toward disclosing the donor conception to the child. It was concluded that infants conceived by egg or sperm donation did not appear to be at risk for parenting difficulties.