- Email: [email protected]
Adoption and Subsequent Conceptions
~
1\
Adoption and Subsequent Conceptions WILLIAM C. WEIR, M.D., and DAVID R. WEIR, M.D.
CONSIDERABLE CONFUSION still exists as to whether adoption increases the probability of conception in the infertile couple. The early reports l -4, 7, 8 were based on studying conception rates only in groups that adopted, without control groups for comparison. Recently two reports on this subject appeared simultaneously.5, 6 In both studies the investigators attempted to develop control groups, but arrived at opposite conclusions. Rock and his co-workers established definite criteria for selecting couples that adopted and that did not adopt. For the non adopting group, 113 couples (3.0%) were selected from 3940 studied in his clinic; for the adopting group, 249 couples (25.0%) from 1000 adopting through a multiple-function child care agency. The latter group was selected from reports of infertility studies by a large number of physicians; the former, a small group of trained investigators. This selection method and the percentage differences of those selected suggest that the groups might not be comparable. No explanation is offered for the fact that 35.4% of the nonadopting group subsequently conceived while only 22.9% of the adopting group did. This disparity of 12.5% can be in part explained by the duration of infertility in each group. The average (mean) barren exposure interval was 7.7 years for the adopting couples but only 5.6 years for the nonadopting couples. Our previous studies 9 ,10 of the conception patterns of treated and untreated couples indicate that this 2.1-year difference in the duration of infertility can be responsible in part for the difference in the two conception rates. Such also again indicates that the 2 groups are not comparable. Sandler's report, that adoption does have a therapeutic effect on subsequent conceptions, was based on a comparison of 3 groups. The adopting group consisted of 32 infertile couples advised to adopt (5 did not). Organic disease was present in 8; 3 had no apparent defects; and 21 had
From the Infertility Clinic of the Maternal Health Association of Cleveland, and the Departments of Obstetrics and Gynecology and Medicine, and the Division of Biometry, Western Reserve University, Cleveland, Ohio. This study was made possible by Grant GM 12302-01 from the National Institutes of Health, U. S. Public Health Service, and by The Brush Foundation of Cleveland.
283
284
WEIR
& WEIR
FERTILITY & STERILITY
some kind of anxiety or emotional problem, but all were reported as potentially fertile. Eighteen couples (56%) conceived. A second group consisted of 208 randomly chosen infertile couples. A subgroup of 20 was diagnosed as having only emotional stress and no organic defects; 11 (55%) of these 20 subsequently conceived. Of the remaining 188 couples with presumed organic defects, tubal occlusion was present in 41 and others were sterile as a result of other defects. Conceptions occurred in 95 (45.5%) of these couples; 15.5% ended in abortion. He suggests that the removal of anxiety and emotional problems through adoption in the first group of 32 couples and the treatment of emotional stress in the second group of 20 couples shows a therapeutic effect on subsequent conception rates when the rates are compared with those of the 188 couples with "organic" defects. When sterile couples are removed from Sandler's group of 188, the conception rate rises to 53% as compared with 56% and 55% for the other two groups. Although the emotional-stress group was observed for a shorter period than were the others, the difference between all 3 groups is evidently not significant. The duration of infertility is reported only in the group of 32 couples that adopted, but not in the other 2 groups. From this standpoint alone, there is no way of knowing whether these groups are comparable or not. His inability to treat those of the adopting group with anxiety and emotional problems and his ability to treat emotional stress successfully in part of the emotional-stress group of 20 that did not adopt would also indicate that the groups are not similar. Lastly, he reports that only 27 couples adopted over a period of 17 years but that the other 2 groups were selected from 600 couples seen over 7 years. Such would indicate that in his area only about 2% of the infertile couples adopt. If this indication were true, selection of comparable groups would be nearly impossible. The inadequacies in the selection of the three groups in this study suggest that the validity of the conclusions is questionable. The purpose of our report is to present data from a single integrated study of infertile couples observed over a period of 18 years by one small group of investigators. Comparable groups of couples have been developed and the results appear to be significant. SUBJECTS
The subjects for this study were the first 736 couples consecutively admitted to this clinic. The following 298 couples were not included in the study: (1) all couples that conceived with a gestation of 20 or more weeks' duration during clinic treatment; (2) all couples with secondary infertility, having had a gestation of 20 or more weeks' duration prior to admission to
VOL.
17, No.2, 1966
CONCEPTION AFTER ADOPTION
285
the clinic; and (3) all couples in which either the man or the woman was absolutely sterile. The remaining 438 couples fulfilled the following requirements: (1) All were potentially fertile. (2) All had had a minimum duration of infertility of B~ years prior to admission to the clinic. ( 3) All had been investigated by standards set up by the American Fertility Society. (4) All had been treated when such was indicated. (5) All had primary infertility problems, in that none had had a gestation of 20 or more weeks' duration prior to admission to the clinic or during the study. ( 6) All had been discharged nonpregnant from the clinic and given routine information about adoption and the availability of adoption agencies. (7) All had been followed for a minimum of 5 years from the time of initial interview at the beginning of their clinic study. Although contact was made with all 5 or more years after their initial interviews, the designated interval to follow-up was less in a few instances, due to hysterectomy, divorce, or other factors causing the couples no longer to seek pregnancy. A group of 197 of the 438 couples adopted. The remaining 241 couples did not adopt and constitute the control group. Table 1 shows the criteria used to compare the two groups, those that adopted and those that did not. Slight but not significant differences are apparent between the two groups. More white than Negro couples adopted. More Protestant and Jewish couples adopted than Catholic. The category of relative fertility needs clarification. In the development of the data for our infertile couples, arbitrary standards were set up to classify all individuals as to their relative fertility. No assumption can be made that these standards are correct, but the same standards were consistently applied to all those studied and are therefore accurate for the comparison of groups. Those couples that adopted were slightly younger than those that did not adopt. One of the more important criteria for comparison purposes is the duration of infertility for the two groups. The average (mean) years of infertility for the adopting group was 4.96 years and for the nonadopting group 5.44 years. The difference of 0.48 years is small. Even when broken down into intervals, the differences would not affect the conception rates. The minor differences in all criteria for both groups do not appear to be significant. Actually the shorter duration of infertility, the younger ages, and the longer duration of observation of the adopting couples might increase the rate of conception in that group as compared with that of the nonadopting couples. The consistent findings in both groups suggest that the two groups are essentially the same and are in fact comparable. The therapeutic effect of adoption, if such exists, may begin at anyone of the following points in time: (1) when a couple fail to conceive and
FERTILITY & STERILITY
WEIR & WEIR
286
TABLE 1. Comparison of 197 Adopting and 241 Nonadopting Couples Adopting
N onadopting
Total
No.
%
No.
%
No.
%
Race White Negro Other
182 14 1
92 7 1
201 38 2
83 16 1
383 52 3
87 12 1
Religion Protestant Catholic Jewish Mixed
109 45 25 18
55 23 13 9
127 65 24 25
53 27
236 110 49 43
54 25 11 10
66 11 50 70
33 6 25 36
88 15 62 76
36 6 26 32
154 112 146
35 6 26 33
2 67 78 50
1 34 40 25
5 66 81 89
2 27 34 37
7 133 159 139
2 30 36 32
19 97 61 20
10 49 31
19 95 78 49
8 39 32 20
38 192 139 69
9 44 32 15
Variable
Relative fertility Man and woman fertile Man and woman impaired Man fertile, woman impaired Man impaired, woman fertile Man's age at initial interview (yr.) Under 25
25-30 30-35 Over 35 Woman's age at initial interview (yr.) Under 25
25-30 30--35 Over 35 Average (mean) age of woman (yr.) Onset of infertility Initial interview Discharge Follow-up
2-4 4-6
6-8 8-10 Over 10 AVERAGE (MEAN) YEARS Time from init. into to discharge (yr.) Under 1
10
26
25.0 30.3 32.5 37.1
25.4 30.9 33.2 37.6
24.6 29.4 31.7 36.5
Time from onset of infertility to init. int. (yr.) Under 2
1-2 2-3
10
10
7 71 60 34 15 10
4 36 30 17 8 5 4.96
17 84 55 32 25 28
7 35 23 13 11 12 5.44
24 155 115 66 40 38
6 35 26 15 9 9 5.22
45 51 54
23 26 27
39 70 69
16 29 29
84 121 123
19 28 28
( Oontinued)
VOL.
17, No.2, 1966
3-4 4-5 Over 5 AVERAGE
287
CONCEPTION AFTER ADOPTION
27 14 6
28 15 20
12 6 8
2.11
(MEAN) YEARS
Time from init. into to follow-up (yr.) Under 2 2-4 4-6 6-8 8-10 Over 10
14 7 3
12
7 6 2.24
2.34
2
1
8
64 35 21
32 18 11
77
8
4
67
34
3 32 15 12
35 30 12 79
5 33
6.95
AVERAGE (MEAN) YEARS
55 29 26
10 141 70 51 20 146
2 32 16 12 5 33
6.86
6.78
first think of the possibility of adoption; (2) when medical evidence suggests adoption as a solution to their fertility problem; (3) when the infertile couple decide to adopt and make formal application to an agency; (4) when they are accepted by an agency and a family study started; (5) when a baby is actually placed in the home. As considerable variations occur between these points, and as some cannot be definitely identified, the time when the baby was actually placed in the home was used in this study as the starting time of the therapeutic effect, if such exists. RESULTS
Table 2 shows the rates of conception for the adopting group as compared to the non-adopting group. The performance of the nonadopting TABLE 2. Time Intervals to Conception for Adopting and Nonadopting Infertile Couples Adopting No.
0/0
Number of couples 197 32 16.2 Number of conceptions 8.88 From onset of infert.: average (mean) years From initial interview (years) 5 16 Under 2 2-4 11 34 12 4-6 38 4 12 Over 6 3.98 AVERAGE (MEAN) YEARS 1.98 From discharge: average (mean) years
N onadopting
Total
No.
0/0
No.
241 44
18.2
438 76
8.06 7 24 10 3
16 54 23 7 3.45 1.36
0/0
17.3 8.40
12 35 22 7
16 46 29 9 3.68 1.63
WEIR & WEIR
288
I
FERTILITY & STERILITY
group, 18.2%, was slightly better than that of the adopting group, 16.2%. This small difference, 2.0%, does not appear significant. For those conceiving, three time intervals are presented (Table 2). Again the non adopting group did slightly better, but with no significant difference. If adoption were important in promoting conception, these time intervals should have been shorter for the adopting group. CONCLUSIONS
1. Of 736 consecutively admitted couples with primary infertility, 438 were discharged nonpregnant but potentially fertile. All had been thoroughly investigated, treated when indicated, and followed for at least 5 years. They were subdivided into 2 groups: 197 that adopted and 241 that did not adopt. 2. In duration of infertility, age, relative infertility, and other criteria, the 2 groups were comparable. 3. Conception rates for the two groups were essentially the same. 4. For those conceiving in both groups, time intervals from various points in the infertility period to conception were essentially the same. 5. The data from this study indicate that adoption, resulting in the physical presence of a baby in the home of an infertile couple, does not increase the chance that conception will occur. Maternal Health Association 2027 Cornell Rd. Cleveland, Ohio 44106
REFERENCES 1. ARONSON, H. G., and GLIENKE, C. F. A study of the incidence of pregnancy following adoption. Fertil. & Steril. 14:547, 1963. 2. BANKS, A. L. Does adoption affect infertility. Internat. J. Fertil. 7:23, 1962. 3. BANKS, A. L., RUTHERFORD, R. N., and COBURN, W. A. Fertility following adoption: report of 31 cases. Fertil. & Steril. 12:438, 1961. 4. HANSON, F. M., and ROCK, J. The effect of adoption on fertility and other reproductive functions. Am.]. Obst. & Gynec. 59:311, 1950.
5. ROCK,
J.,
TIETZE, C., and McLAUGHLIN, H. B. Effect of adoption on infertility.
Fertil. & Steril. 16:305, 1965. 6. SANDLER, B. Conception after adoption: A comparison of conception rates. Fertil. & Steril. 16:313, 1965. 7. TYLER, E. T., BONAPART, J., and GRANT, J. Occurrence of pregnancy following adoption. Fertil. & Steril. 11:581, 1960. 8. WEINSTEIN, E. A. Adoption and infertility. Am. Social. Rev. 27:408, 1962. 9. WEIR, W. C., and CICCHINELLI, A. L. Prognosis for the infertile couple. Fertil. & Steril. 15:625, 1964. 10. WEIR, W. C., and WEIR, D. R. The natural history of infertility. Fertil. & Steril. 12:443, 1961.
1\
Adoption and Subsequent Conceptions WILLIAM C. WEIR, M.D., and DAVID R. WEIR, M.D.
CONSIDERABLE CONFUSION still exists as to whether adoption increases the probability of conception in the infertile couple. The early reports l -4, 7, 8 were based on studying conception rates only in groups that adopted, without control groups for comparison. Recently two reports on this subject appeared simultaneously.5, 6 In both studies the investigators attempted to develop control groups, but arrived at opposite conclusions. Rock and his co-workers established definite criteria for selecting couples that adopted and that did not adopt. For the non adopting group, 113 couples (3.0%) were selected from 3940 studied in his clinic; for the adopting group, 249 couples (25.0%) from 1000 adopting through a multiple-function child care agency. The latter group was selected from reports of infertility studies by a large number of physicians; the former, a small group of trained investigators. This selection method and the percentage differences of those selected suggest that the groups might not be comparable. No explanation is offered for the fact that 35.4% of the nonadopting group subsequently conceived while only 22.9% of the adopting group did. This disparity of 12.5% can be in part explained by the duration of infertility in each group. The average (mean) barren exposure interval was 7.7 years for the adopting couples but only 5.6 years for the nonadopting couples. Our previous studies 9 ,10 of the conception patterns of treated and untreated couples indicate that this 2.1-year difference in the duration of infertility can be responsible in part for the difference in the two conception rates. Such also again indicates that the 2 groups are not comparable. Sandler's report, that adoption does have a therapeutic effect on subsequent conceptions, was based on a comparison of 3 groups. The adopting group consisted of 32 infertile couples advised to adopt (5 did not). Organic disease was present in 8; 3 had no apparent defects; and 21 had
From the Infertility Clinic of the Maternal Health Association of Cleveland, and the Departments of Obstetrics and Gynecology and Medicine, and the Division of Biometry, Western Reserve University, Cleveland, Ohio. This study was made possible by Grant GM 12302-01 from the National Institutes of Health, U. S. Public Health Service, and by The Brush Foundation of Cleveland.
283
284
WEIR
& WEIR
FERTILITY & STERILITY
some kind of anxiety or emotional problem, but all were reported as potentially fertile. Eighteen couples (56%) conceived. A second group consisted of 208 randomly chosen infertile couples. A subgroup of 20 was diagnosed as having only emotional stress and no organic defects; 11 (55%) of these 20 subsequently conceived. Of the remaining 188 couples with presumed organic defects, tubal occlusion was present in 41 and others were sterile as a result of other defects. Conceptions occurred in 95 (45.5%) of these couples; 15.5% ended in abortion. He suggests that the removal of anxiety and emotional problems through adoption in the first group of 32 couples and the treatment of emotional stress in the second group of 20 couples shows a therapeutic effect on subsequent conception rates when the rates are compared with those of the 188 couples with "organic" defects. When sterile couples are removed from Sandler's group of 188, the conception rate rises to 53% as compared with 56% and 55% for the other two groups. Although the emotional-stress group was observed for a shorter period than were the others, the difference between all 3 groups is evidently not significant. The duration of infertility is reported only in the group of 32 couples that adopted, but not in the other 2 groups. From this standpoint alone, there is no way of knowing whether these groups are comparable or not. His inability to treat those of the adopting group with anxiety and emotional problems and his ability to treat emotional stress successfully in part of the emotional-stress group of 20 that did not adopt would also indicate that the groups are not similar. Lastly, he reports that only 27 couples adopted over a period of 17 years but that the other 2 groups were selected from 600 couples seen over 7 years. Such would indicate that in his area only about 2% of the infertile couples adopt. If this indication were true, selection of comparable groups would be nearly impossible. The inadequacies in the selection of the three groups in this study suggest that the validity of the conclusions is questionable. The purpose of our report is to present data from a single integrated study of infertile couples observed over a period of 18 years by one small group of investigators. Comparable groups of couples have been developed and the results appear to be significant. SUBJECTS
The subjects for this study were the first 736 couples consecutively admitted to this clinic. The following 298 couples were not included in the study: (1) all couples that conceived with a gestation of 20 or more weeks' duration during clinic treatment; (2) all couples with secondary infertility, having had a gestation of 20 or more weeks' duration prior to admission to
VOL.
17, No.2, 1966
CONCEPTION AFTER ADOPTION
285
the clinic; and (3) all couples in which either the man or the woman was absolutely sterile. The remaining 438 couples fulfilled the following requirements: (1) All were potentially fertile. (2) All had had a minimum duration of infertility of B~ years prior to admission to the clinic. ( 3) All had been investigated by standards set up by the American Fertility Society. (4) All had been treated when such was indicated. (5) All had primary infertility problems, in that none had had a gestation of 20 or more weeks' duration prior to admission to the clinic or during the study. ( 6) All had been discharged nonpregnant from the clinic and given routine information about adoption and the availability of adoption agencies. (7) All had been followed for a minimum of 5 years from the time of initial interview at the beginning of their clinic study. Although contact was made with all 5 or more years after their initial interviews, the designated interval to follow-up was less in a few instances, due to hysterectomy, divorce, or other factors causing the couples no longer to seek pregnancy. A group of 197 of the 438 couples adopted. The remaining 241 couples did not adopt and constitute the control group. Table 1 shows the criteria used to compare the two groups, those that adopted and those that did not. Slight but not significant differences are apparent between the two groups. More white than Negro couples adopted. More Protestant and Jewish couples adopted than Catholic. The category of relative fertility needs clarification. In the development of the data for our infertile couples, arbitrary standards were set up to classify all individuals as to their relative fertility. No assumption can be made that these standards are correct, but the same standards were consistently applied to all those studied and are therefore accurate for the comparison of groups. Those couples that adopted were slightly younger than those that did not adopt. One of the more important criteria for comparison purposes is the duration of infertility for the two groups. The average (mean) years of infertility for the adopting group was 4.96 years and for the nonadopting group 5.44 years. The difference of 0.48 years is small. Even when broken down into intervals, the differences would not affect the conception rates. The minor differences in all criteria for both groups do not appear to be significant. Actually the shorter duration of infertility, the younger ages, and the longer duration of observation of the adopting couples might increase the rate of conception in that group as compared with that of the nonadopting couples. The consistent findings in both groups suggest that the two groups are essentially the same and are in fact comparable. The therapeutic effect of adoption, if such exists, may begin at anyone of the following points in time: (1) when a couple fail to conceive and
FERTILITY & STERILITY
WEIR & WEIR
286
TABLE 1. Comparison of 197 Adopting and 241 Nonadopting Couples Adopting
N onadopting
Total
No.
%
No.
%
No.
%
Race White Negro Other
182 14 1
92 7 1
201 38 2
83 16 1
383 52 3
87 12 1
Religion Protestant Catholic Jewish Mixed
109 45 25 18
55 23 13 9
127 65 24 25
53 27
236 110 49 43
54 25 11 10
66 11 50 70
33 6 25 36
88 15 62 76
36 6 26 32
154 112 146
35 6 26 33
2 67 78 50
1 34 40 25
5 66 81 89
2 27 34 37
7 133 159 139
2 30 36 32
19 97 61 20
10 49 31
19 95 78 49
8 39 32 20
38 192 139 69
9 44 32 15
Variable
Relative fertility Man and woman fertile Man and woman impaired Man fertile, woman impaired Man impaired, woman fertile Man's age at initial interview (yr.) Under 25
25-30 30-35 Over 35 Woman's age at initial interview (yr.) Under 25
25-30 30--35 Over 35 Average (mean) age of woman (yr.) Onset of infertility Initial interview Discharge Follow-up
2-4 4-6
6-8 8-10 Over 10 AVERAGE (MEAN) YEARS Time from init. into to discharge (yr.) Under 1
10
26
25.0 30.3 32.5 37.1
25.4 30.9 33.2 37.6
24.6 29.4 31.7 36.5
Time from onset of infertility to init. int. (yr.) Under 2
1-2 2-3
10
10
7 71 60 34 15 10
4 36 30 17 8 5 4.96
17 84 55 32 25 28
7 35 23 13 11 12 5.44
24 155 115 66 40 38
6 35 26 15 9 9 5.22
45 51 54
23 26 27
39 70 69
16 29 29
84 121 123
19 28 28
( Oontinued)
VOL.
17, No.2, 1966
3-4 4-5 Over 5 AVERAGE
287
CONCEPTION AFTER ADOPTION
27 14 6
28 15 20
12 6 8
2.11
(MEAN) YEARS
Time from init. into to follow-up (yr.) Under 2 2-4 4-6 6-8 8-10 Over 10
14 7 3
12
7 6 2.24
2.34
2
1
8
64 35 21
32 18 11
77
8
4
67
34
3 32 15 12
35 30 12 79
5 33
6.95
AVERAGE (MEAN) YEARS
55 29 26
10 141 70 51 20 146
2 32 16 12 5 33
6.86
6.78
first think of the possibility of adoption; (2) when medical evidence suggests adoption as a solution to their fertility problem; (3) when the infertile couple decide to adopt and make formal application to an agency; (4) when they are accepted by an agency and a family study started; (5) when a baby is actually placed in the home. As considerable variations occur between these points, and as some cannot be definitely identified, the time when the baby was actually placed in the home was used in this study as the starting time of the therapeutic effect, if such exists. RESULTS
Table 2 shows the rates of conception for the adopting group as compared to the non-adopting group. The performance of the nonadopting TABLE 2. Time Intervals to Conception for Adopting and Nonadopting Infertile Couples Adopting No.
0/0
Number of couples 197 32 16.2 Number of conceptions 8.88 From onset of infert.: average (mean) years From initial interview (years) 5 16 Under 2 2-4 11 34 12 4-6 38 4 12 Over 6 3.98 AVERAGE (MEAN) YEARS 1.98 From discharge: average (mean) years
N onadopting
Total
No.
0/0
No.
241 44
18.2
438 76
8.06 7 24 10 3
16 54 23 7 3.45 1.36
0/0
17.3 8.40
12 35 22 7
16 46 29 9 3.68 1.63
WEIR & WEIR
288
I
FERTILITY & STERILITY
group, 18.2%, was slightly better than that of the adopting group, 16.2%. This small difference, 2.0%, does not appear significant. For those conceiving, three time intervals are presented (Table 2). Again the non adopting group did slightly better, but with no significant difference. If adoption were important in promoting conception, these time intervals should have been shorter for the adopting group. CONCLUSIONS
1. Of 736 consecutively admitted couples with primary infertility, 438 were discharged nonpregnant but potentially fertile. All had been thoroughly investigated, treated when indicated, and followed for at least 5 years. They were subdivided into 2 groups: 197 that adopted and 241 that did not adopt. 2. In duration of infertility, age, relative infertility, and other criteria, the 2 groups were comparable. 3. Conception rates for the two groups were essentially the same. 4. For those conceiving in both groups, time intervals from various points in the infertility period to conception were essentially the same. 5. The data from this study indicate that adoption, resulting in the physical presence of a baby in the home of an infertile couple, does not increase the chance that conception will occur. Maternal Health Association 2027 Cornell Rd. Cleveland, Ohio 44106
REFERENCES 1. ARONSON, H. G., and GLIENKE, C. F. A study of the incidence of pregnancy following adoption. Fertil. & Steril. 14:547, 1963. 2. BANKS, A. L. Does adoption affect infertility. Internat. J. Fertil. 7:23, 1962. 3. BANKS, A. L., RUTHERFORD, R. N., and COBURN, W. A. Fertility following adoption: report of 31 cases. Fertil. & Steril. 12:438, 1961. 4. HANSON, F. M., and ROCK, J. The effect of adoption on fertility and other reproductive functions. Am.]. Obst. & Gynec. 59:311, 1950.
5. ROCK,
J.,
TIETZE, C., and McLAUGHLIN, H. B. Effect of adoption on infertility.
Fertil. & Steril. 16:305, 1965. 6. SANDLER, B. Conception after adoption: A comparison of conception rates. Fertil. & Steril. 16:313, 1965. 7. TYLER, E. T., BONAPART, J., and GRANT, J. Occurrence of pregnancy following adoption. Fertil. & Steril. 11:581, 1960. 8. WEINSTEIN, E. A. Adoption and infertility. Am. Social. Rev. 27:408, 1962. 9. WEIR, W. C., and CICCHINELLI, A. L. Prognosis for the infertile couple. Fertil. & Steril. 15:625, 1964. 10. WEIR, W. C., and WEIR, D. R. The natural history of infertility. Fertil. & Steril. 12:443, 1961.