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

Egg donation parents and their children: follow-up at age 12 years Clare Murray, Ph.D., Fiona MacCallum, Ph.D., and Susan Golombok, Ph.D. Family and Child Psychology Research Centre, City University, London, United Kingdom

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 overinvolved 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. (Fertil Steril威 2006;85:610 – 8. ©2006 by American Society for Reproductive Medicine.) Key Words: Egg donation, adolescence, parent– child relationships, children’s psychological adjustment

In contrast to such assisted reproductive techniques as IVF and donor insemination (DI), egg donation is a more recent development. The introduction of this procedure in 1983 (1, 2) saw the emergence of yet another new type of family. In egg donation, the father’s sperm is used to fertilize the donated egg, and the resulting embryo is then transferred into the mother’s uterus. Thus, egg donation provides infertile women with the unique opportunity to become pregnant with and give birth to a child to whom they are not genetically related. The increasing number of families created by egg donation has raised issues of concern regarding family relationships and, in particular, children’s psychological well-being. Some of these concerns are not specifically related to egg donation but reflect general unease about the impact of the experience of infertility on parenting. For example, it has been argued that the stress associated with infertility, coupled with the often difficult and protracted nature of infertility treatment, might make parents more likely to be overprotective and emotionally over-involved with their child (3) and to form unrealistic expectations of their child (4). It is often the case that egg donation couples have already experienced a number of failed IVF cycles and have opted to use Received September 30, 2004; revised and accepted August 30, 2005. Supported by the Wellcome Trust, London, United Kingdom. Reprint requests: Susan Golombok, Ph.D., Centre for Family Research, University of Cambridge, Free School Lane, Cambridge CB2 3RF, United Kingdom (E-mail: [email protected]).

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this procedure as a last resort. Thus, these couples might be more vulnerable to the negative impact of their experiences of infertility on their parenting ability. By far the greatest concern regarding the use of donated eggs relates to the fact that very few children who are born this way are aware of the nature of their conception. It is argued that it is the secrecy surrounding the child’s conception that is likely to have the most damaging effect on family relationships and the child’s psychological well-being (5–7). According to family therapists, secrets in families threaten the harmony of family relationships, distancing those family members who know the secret from those who do not (8). Research suggests that children often become aware that information is being kept from them because certain subjects have become taboo in family discussions. Parents might communicate this both verbally and nonverbally (e.g., tone of voice, quickly changing the subject, facial expression, and body posture) (9). As a result, children might become confused and anxious and might even go on to develop symptoms of psychological disorder (10). Another concern sometimes raised in relation to egg donation families is that the lack of a genetic tie between mother and child might in itself negatively affect the mother’s parenting ability and have a detrimental effect on the child’s psychological adjustment. Because of the absence of a genetic relationship, it is possible that mothers whose children were conceived by egg donation might be more distant or might find it harder to form a relationship with their child

Fertility and Sterility姞 Vol. 85, No. 3, March 2006 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.

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than do genetically related mothers, which might exert a negative influence on children’s psychological well-being. However, it is equally plausible that the experience of being pregnant with and giving birth to a child might compensate for the absence of a genetic link. Findings from one small study conducted during pregnancy suggest that this might be the case (11), with egg donation mothers reporting that undergoing the pregnancy enhanced the feeling that the child was truly their own (genetic) child. Egg donation families resemble adoptive families in that egg donation mothers lack a genetic link with their child. On the whole, mother– child relationships in adoptive families have been found to be positive when the child has been adopted at birth (12, 13), the situation that most resembles egg donation families. This suggests that difficulties would not necessarily be expected in mother– child relationships in egg donation families. Furthermore, egg donation differs from adoption in that the mother is pregnant with and gives birth to the child, the child is genetically related to the father, and the child has not been relinquished for adoption by the birth parents. Studies of DI families, which are similar to egg donation families in that there is a missing genetic link between one parent (i.e., the father) and the child, indicate that DI parents show greater warmth toward their children, are more emotionally involved with them, and interact with them more on a daily basis than do parents of naturally conceived children (14, 15). Little research has been conducted on parents and children in families created by egg donation, partly owing to the fact that egg donation is a more recent procedure than other types of assisted reproduction, such as IVF and DI. In addition, the secrecy that often surrounds the use of a donated egg has made it difficult to recruit these families for research. The focus of the present study was on the quality of parenting and the psychological adjustment of egg donation children and their parents. Although the sample was small because these were the first egg donation families in the United Kingdom (UK), it is the first controlled study to conduct in-depth standardized interviews with a representative sample of egg donation mothers and their children. In the first phase of the study, when the children were aged approximately 4.5 years, it was found that egg donation was associated with greater parental psychological well-being compared with DI, IVF, and adoption and did not interfere with the quality of parenting. The children conceived by egg donation were not experiencing raised levels of psychological problems, as assessed by parents and according to data obtained from the children themselves (16). Interestingly, only one set of egg donation parents had told their child about his or her donor origins. This article reports on the follow-up of the egg donation families as the children reached adolescence. Insofar as the experiences of adopted children can be extrapolated to egg donation children, early adolescence is the time when adopted children begin to exhibit higher rates of behavioral Fertility and Sterility姞

problems than nonadopted children (17, 18), as well as an increased interest in their birth parents (19). However, the difficulties experienced by some adopted children might be partly due to a negative reaction to the knowledge that they had been relinquished for adoption by their birth parents, a situation that does not apply to egg donation. Although the earlier findings from the present sample suggested that egg donation children and their parents were generally functioning well, it is not known whether this pattern continues throughout childhood and into adolescence. Adolescence represents an important developmental milestone, with specific psychological challenges for both parents and children to negotiate. For example, for children, establishing a sense of identity and autonomy are normative developmental tasks of adolescence. This might conflict with the parents’ wish to maintain their children’s dependence (20). The increasing autonomy of their children might present particular challenges for egg donation parents. Specific aspects of egg donation, such as the potential for parents to be overprotective of and emotionally over-involved with their child, might detrimentally affect parent– child relationships. In addition, for adolescents, the search for a firm awareness of who they are might involve an increased focus on which parent they look most like. For those egg donation parents who have chosen not to tell their child about his or her donor origins, such situations might increase children’s uncertainty and anxiety. Thus, adolescence might be a particularly difficult time for both parents and children in egg donation families. The aim of the present study was to examine the outcomes for parenting and child development at adolescence of the absence of a genetic link between the mother and the child. MATERIALS AND METHODS Participants At the time of the first phase of the study, families were asked for permission to contact them again for follow-up (for details of the recruitment of participants to the initial study, see Golombok et al. [16]). Ethical approval for the present study was obtained from the City University Ethics Committee. Those families who agreed to follow-up were contacted either by telephone or by letter as close as possible to the child’s 12th birthday. Seventeen families with a child conceived by egg donation and comparison groups of 35 families with a child conceived by donor insemination (DI) and 34 families with a child conceived by IVF agreed to participate in the follow-up study. The response rate for egg donation, DI, and IVF families was 84%, 82%, and 83% respectively. All the mothers were seen in the present investigation, and 84% of the children participated. Demographics Of the parents, 76 couples were married or cohabiting at the time of the study. Eight couples had divorced or separated 611

since the birth of the target child (6 DI and 2 IVF parents), and 2 DI fathers had died. No significant differences were found between the family types with regard to marital status, excluding the 2 DI families in which the father had died. Differences were found, however, for mother’s age [F(2, 85) ⫽ 7.41, P⬍.05]. Egg donation mothers were the oldest (mean age, 47 years), and the DI mothers were the youngest (mean age, 43 years).

ences with regard to the proportion of mothers or children who agreed to take part. Measures Parents’ Marital and Psychological State. For those couples who were intact, mothers completed the Golombok Rust Inventory of Marital State (GRIMS) (22, 23), a questionnaire designed to assess the quality of the marital relationship. All mothers completed the State-Trait Anxiety Inventory (STAI) (24) and the Beck Depression Inventory (BDI) (25, 26), questionnaire measures of anxiety and depression, respectively. All three of these instruments have been shown to have good reliability and to discriminate well between clinical and nonclinical groups. For each questionnaire, a high score represented problematic behavior.

No significant group differences were found for social class as measured by the father’s occupation, according to a modified version of the Registrar General’s classification (21) ranging from 1 (professional/managerial) to 4 (partly skilled or unskilled). There were similar proportions of girls and boys in each group, and no differences were found for the age of the target child at the time of study. Similarly, there was no significant difference between groups for family size (see Table 1). The demographic variable that differed significantly between family types (mother’s age) was included as a covariate in all further analyses.

Parent–Child Relationships. All mothers were interviewed with an adaptation of a standardized interview designed to assess quality of parenting (27). This procedure has been validated against observational ratings of mother– child relationships in the home and has demonstrated a high level of agreement between global ratings of the quality of parenting by interviewers and observers. Detailed accounts were obtained of the child’s behavior and the mother’s response to it, with respect to the child’s progress at school, peer adjustment, and relationships within the family unit. Particular attention was paid to parent– child interactions relating to issues of parental warmth and control, as well as to the child’s social and emotional development. Information obtained by interview was rated according to a standardized coding scheme, and regular meetings were held to minimize

Procedure All families were visited at home by a trained researcher. Data were obtained from the mother and child by way of a standardized interview and questionnaire. All interviews were tape-recorded. In the majority of cases, two visits were made to each family. The first visit was to interview the mother (interviews usually lasted between 1 and 2 hours), and the second was to interview the child (an interview of 45– 60 minutes). Questionnaire data were obtained from 75 mothers and 64 of the children. There were no group differ-

TABLE 1 Demographic characteristics of participants by family type.

Age of target child (mo) Age of mother (y) Father’s occupation 1 2 3 4 No. of boys No. of girls No. of siblings in household 0 1 2 3

Egg donation

Donor insemination

IVF

F or ␹2 a

P

139.29 ⫾ 7.39 47.70 ⫾ 4.46

142.49 ⫾ 8.66 43.20 ⫾ 4.39

143.65 ⫾ 7.47 46.08 ⫾ 4.09

F ⫽ 1.70 F ⫽ 7.41

NS ⬍.05

11 (65) 6 (35) 0 0 9 (53) 8 (47)

18 (51) 9 (26) 8 (23) 0 19 (54) 16 (46)

19 (56) 7 (21) 8 (22) 0 24 (71) 10 (29)

␹2 ⫽ 6.05

NS

12 (71) 3 (17) 2 (12) 0

14 (40) 15 (43) 5 (14) 1 (3)

18 (53) 11 (32) 5 (15) 0

␹2 ⫽ 5.89

NS

NS

Note: Values are mean ⫾ SD or n (%). NS ⫽ not significant. a Fisher’s exact test was used for all ␹2. Murray. Egg donation families at age 12. Fertil Steril 2006.

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rater discrepancy. To calculate interrater reliabilities, 57 randomly selected interviews were coded by a second interviewer, “blind” to family type. Agreement between raters ranged from 95% to 100% for all the variables used, with nonagreement defined as a ⬎1-point difference on any scale (28). Global ratings of the quality of parenting were made, based on information obtained from the entire interview: 1. Expressed warmth was rated on a 6-point scale from 0 (none) to 5 (high). Aspects of warmth considered for this rating included tone of voice, facial expression, and gestures when speaking about the child; spontaneous expressions of warmth, sympathy, and concern about the child’s difficulties (if they had any); and the degree of interest in the child as a person. 2. Sensitive responding was rated on a 5-point scale from 0 (none) to 4 (very sensitive responding) and represented the mother’s ability to recognize and respond appropriately to her child’s anxieties and fears. 3. Emotional over-involvement was rated on a 4-point scale from 0 (no over-involvement) to 3 (enmeshed). This rating took into account the extent to which the parent was over-concerned or overprotective toward the child and the extent to which the parent had interests apart from those relating to the child. 4. Supervision was rated on a 5-point scale from 0 (very inadequate) to 4 (over-supervised). This rating was based on the mother’s age-appropriate monitoring of the child’s activities. 5. Disciplinary indulgence was rated on a 6-point scale from 0 (indulgent) to 5 (none) and measured the degree of negotiation between mother and child with regard to control issues. 6. Disciplinary aggression was rated on a 6-point scale form 0 (none) to 5 (abusive). This rating assessed irritability, loss of temper, and physical aggression shown by the mother toward the child during disciplinary interactions. Systematic information was also obtained from all of the mothers about their attitudes toward disclosure about the child’s donor conception to produce the following variables: [1] whether or not they had told or planned to tell their child about his/her method of conception, [2] if not, their reasons for not telling, and [3] if so, their reasons for telling. For those mothers who did not intend to be open with their child, each of the following variables was coded as “yes” or “no,” according to the mothers’ responses: [1] to protect the child, [2] to protect the father, [3] to protect the mother, and [4] there is no need to tell. With the same coding method, the responses of those mothers who had told or who intended to tell their child were rated according to the following criteria: [1] the child has a right to know, [2] to avoid intermarriage, and [3] to avoid disclosure from someone other than the parents. One section of the mother’s quality of parenting interview assessed the extent to which the mother perceived the father to be a help or a hindrance in parenting. Four ratings were made: Fertility and Sterility姞

1. Father’s help in control was rated on a 7-point scale from 1 (exacerbates issues) to 7 (takes the load) and measured how much the father helped the mother when she was engaged in control issues with the child. 2. Reliability of father in parenting support was rated on a 5-point scale from 0 (no support) to 4 (very reliable) and measured whether the father could be called upon and trusted to take some parental responsibility. 3. Load-taking of the father was rated on a 5-point scale from 0 (none) to 4 (major parenting load) and was specifically concerned with the father taking care of the child to allow the mother some free time to engage in other activities. Children’s Socioemotional Development. The following ratings regarding the child’s adjustment at school were made from the interview with the mother: [1] interest in schoolwork was rated on a 5-point scale from 0 (no interest/effort) to 4 (keen on most subjects) and assessed the child’s interest in academic subjects, and [2] worries about teachers was measured on a 4-point scale from 0 (none) to 3 (major) and was a rating of worries expressed by the child to the mother about relationships with teachers. In addition, the child’s relationships with peers were measured with ratings of [3] worries about relationships at school, rated on a 4-point scale from 0 (none) to 3 (major), which assessed the child’s worries about relationships with other children at school (e.g., not having any friends or being bullied), and [4] peer problems, which was rated on a 4-point scale from 0 (no problems) to 3 (very many problems) and measured the mother’s perception of the extent to which the child seemed to have difficulties in making and keeping friends. The children’s own views of their school and peer adjustment were assessed by the Child and Adolescent Functioning and Environment Schedule (29), a semistructured interview designed to obtain information on the child’s functioning at school and relationships with peers. For the present investigation, the following ratings were used: 1. Interest/effort in schoolwork was rated on a 5-point scale form 0 (no interest/effort) to 4 (above-average interest in most areas) and measured the children’s interest and effort in both academic and nonacademic subjects. 2. Confidence in school performance was rated on a 4-point scale from 0 (none in any subject) to 3 (very confident in most) and measured children’s confidence in their own abilities at school. 3. Confidence in relationships was rated on a 4-point scale from 0 (not at all confident) to 3 (very confident) and assessed children’s confidence in their peer relationships. 4. Bullying was rated on a 4-point scale from 0 (never) to 3 (chronic and/or serious) and assessed whether children had ever been bullied and the severity of the incidents. The presence of behavioral or emotional problems in children was assessed with the Strengths and Difficulties Questionnaire (SDQ) (30, 31), administered to the mother. The SDQ produces an overall score of the child’s adjustment (total deviance), along with five subscale scores, three of 613

TABLE 2 Mothers’ marital and psychological state by family type.

Mothers’ GRIMS Mothers’ BDI Mothers’ STAI

Egg donation

Donor insemination

IVF

F

P

24.23 ⫾ 13.29 5.17 ⫾ 4.68 35.77 ⫾ 8.60

22.88 ⫾ 10.97 5.39 ⫾ 4.68 32.58 ⫾ 8.00

28.56 ⫾ 9.92 5.48 ⫾ 4.7 34.46 ⫾ 8.83

1.84 0.55 0.797

NS NS NS

Note: Values are mean ⫾ SD. Murray. Egg donation families at age 12. Fertil Steril 2006.

which were used in the present study: conduct problems, emotional difficulties, and peer problems. For each scale, higher scores represent higher levels of problematic behavior. The questionnaire has been shown to have good interrater reliability and validity. In addition, the SDQ discriminates between clinical and nonclinical samples. RESULTS Mothers’ Marital and Psychological State According to one-way analyses of covariance, no group differences were found for the extent of marital satisfaction, as assessed by the GRIMS, or for depression or anxiety, as measured by the BDI and STAI, respectively (Table 2). Quality of Parenting: Global Ratings Analyses of covariance were carried out for each of the global quality of parenting variables (expressed warmth, sensitive responding, emotional involvement, supervision, disciplinary indulgence and disciplinary aggression), obtained from the mother’s interview. Where a significant

difference was found between the family types, the following contrast analyses were performed to address particular questions: [1] egg donation mothers vs. IVF mothers (ED vs. IVF). This contrast assessed whether families in which one parent (the mother) lacked a genetic link to the child were different from families in which both parents were genetically related to the child; and [2] egg donation mothers vs. DI mothers (ED vs. DI). This contrast examined whether families in which the child was genetically unrelated to the mother differed from families in which the child was genetically unrelated to the father. No group differences were found for expressed warmth, supervision, disciplinary aggression, or disciplinary indulgence. However, a significant difference between family types was found for sensitive responding [F(2, 82) ⫽ 2.95, P⫽.05]. Contrast analyses revealed that egg donation mothers demonstrated significantly lower levels of sensitive responding than did DI mothers (user contrast [ED vs. DI], P⬍.05), but the contrast between egg donation and IVF mothers was not significant. The level of emotional over-

TABLE 3 Comparisons of quality of parenting measures and mother– child relationship measures between family types. Contrasts Overall ratings Expressed warmth Sensitive responding Emotional overinvolvement Supervision Disciplinary indulgence Disciplinary aggression

Egg donation

Donor insemination

IVF

F

P

ED vs. DIa

ED vs. IVFa

4.00 ⫾ 0.86 2.24 ⫾ 0.43 0.41 ⫾ 0.61

4.29 ⫾ 0.57 2.69 ⫾ 0.83 0.71 ⫾ 0.71

4.09 ⫾ 0.71 2.53 ⫾ 0.66 0.41 ⫾ 0.60

1.15 2.95 3.44

NS .05 ⬍.05

⬍0.05 ⬍0.05

NS NS

3.00 ⫾ 0.50 1.94 ⫾ 0.96 1.29 ⫾ 0.58

2.89 ⫾ 0.58 1.94 ⫾ 0.68 1.26 ⫾ 0.56

3.03 ⫾ 0.57 2.09 ⫾ 0.66 1.38 ⫾ 0.69

0.59 0.40 0.39

NS NS NS

Note: Values are mean ⫾ SD. ED ⫽ egg donation. a User contrast. Murray. Egg donation families at age 12. Fertil Steril 2006.

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involvement also differed between the family types [F(2, 82) ⫽ 3.44, P⬍.05]. Contrast analyses showed that DI mothers were significantly more emotionally over-involved with their children than were egg donation mothers (user contrast [ED vs. DI], P⬍.05). The contrast between egg donation and IVF mothers was not significant (Table 3).

Egg donation mothers perceived their partners to take significantly less of the parenting load than did DI mothers (user contrast [ED vs. DI], P⬍.01). The contrast between egg donation and IVF mothers was also significant, with egg donation mothers reporting their partners to take less of the parenting load than did IVF mothers.

Father’s Contribution to Parenting One-way analyses of covariance were conducted on the variables from the mothers’ interview assessing the mother’s perception of father’s help in parenting (father’s help in control, reliability of father in parenting support, and loadtaking of father). No significant differences were found between the groups for father’s help in control. However, a significant difference was found between the different types of family for general reliability of the father in parenting support [F(2, 74) ⫽ 4.06, P⬍.05]. Contrast analyses revealed that egg donation mothers reported their partners to be significantly less reliable in parenting support than did DI mothers (user contrast [ED vs. DI], P⬍.05). There was no difference between egg donation mothers and IVF mothers for this variable. Perceptions of father’s load-taking also differed between the family types [F(2, 76) ⫽ 4.41, P⬍.05].

Children’s Socioemotional Development School Adjustment. Analyses of covariance were carried out on the variables relating to the child’s functioning at school, derived from the mother interview (interest in schoolwork and worries about teachers) and the child interview (interest/effort in schoolwork and confidence in schoolwork). No group differences were found for any of these variables (Table 4). Peer Relationships. Analyses of covariance were conducted on the two variables from the mother interview relating to children’s relationships with their peers (worries about relationships at school and peer problems) and the two variables from the child interview (confidence in peer relationships and bullying). No group differences were found for either of the variables from the mother interview. Regarding the child interview, no group differences between the family types

TABLE 4 Comparisons of children’s socioemotional development between family types. Contrasts

Children’s school adjustment Interest in schoolwork (mother interview) Worries about teachers (mother interview) Interest/effort in schoolwork (child interview) Children’s peer relationships Worries about relationships (mother interview) Peer problems (mother interview) Confidence in peer relationships (child interview) Bullying (child interview) Strength and Difficulties Questionnaire Emotional difficulties Conduct problems Peer problems Overall score

Egg donation

Donor insemination

2.94 ⫾ 0.42

3.31 ⫾ 0.79

3.03 ⫾ 1.00 0.83

NS

0.24 ⫾ 0.66

0.43 ⫾ 0.60

0.32 ⫾ 0.63 0.44

NS

2.77 ⫾ 0.43

3.22 ⫾ 0.70

3.00 ⫾ 0.81 1.73

NS

0.24 ⫾ 0.43

0.60 ⫾ 0.97

0.32 ⫾ 0.72 1.22

NS

0.35 ⫾ 0.49

0.63 ⫾ 0.80

0.48 ⫾ 0.83 0.65

NS

1.69 ⫾ 0.48

2.10 ⫾ 0.56

2.00 ⫾ 0.66 2.48

NS

0.15 ⫾ 0.55

0.69 ⫾ 0.93

0.25 ⫾ 0.64 3.28 ⬍.05 ⬍0.05

1.23 ⫾ 2.00 1.00 ⫾ 1.47 1.00 ⫾ 1.22 5.23 ⫾ 4.00

1.61 ⫾ 1.49 0.88 ⫾ 0.99 1.03 ⫾ 1.04 6.00 ⫾ 4.38

1.57 ⫾ 2.04 1.23 ⫾ 1.13 1.73 ⫾ 2.13 7.93 ⫾ 5.47

IVF

F

0.18 0.64 1.93 1.91

P

ED vs. ED vs. DIa IVFa

NS

NS NS NS NS

Note: Values are mean ⫾ SD. Murray. Egg donation families at age 12. Fertil Steril 2006.

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were found for children’s confidence in peer relationships. A significant difference was found, however, for children’s reports of bullying [F(2, 69) ⫽ 3.28, P⬍.05]. Contrast analyses showed that egg donation children reported significantly less frequent and/or serious incidences of bullying than did DI children (user contrast [ED vs. DI], P⬍.05). The contrast between egg donation and IVF children for this variable was not significant (Table 4). Strengths and Difficulties Questionnaire. Analyses of covariance were carried out on each of the three subscales (emotional difficulties, conduct problems, and peer problems) and the overall deviance score of the SDQ, completed by mothers. No group differences were found for any of these variables (Table 4). Attitudes Toward Disclosure Telling the Child. Chi-square analyses revealed significant differences between the groups with respect to the mother’s decision to disclose the donor conception to her child. Significantly fewer egg donation (35%) and DI mothers (11%) had already told or planned to tell their child compared with IVF mothers (88%) (␹2 ⫽ 48.7, P⬍.001). Further ␹2 analyses were carried out to determine whether there was a difference between egg donation and DI mothers in terms of their decision to tell their child. No significant differences were found between the two groups of mothers on this variable. Reasons for Nondisclosure. Those mothers who had planned never to tell their child or who were undecided (65% egg donation, 89% DI, and 12% IVF mothers) were asked to give the main reason for their decision. Where more than one reason was given, this was also noted. For the majority of these mothers (82% egg donation, 84% DI, and 25% IVF mothers), nondisclosure stemmed from the desire to protect their child from the possible negative effects that they believed this information might have on his/her psychological well-being. Reasons for Disclosure. Similarly, those mothers who had already told or who planned to tell their child (35% egg donation, 11% DI, and 88% IVF mothers) were asked to give the reason for their decision. The main reason for disclosure stemmed from a strong belief that the child had a right to know about the circumstances surrounding his/her conception (cited by 50% egg donation, 75% DI, and 97% IVF mothers). DISCUSSION The findings of this follow-up study demonstrate that there was no difference in the quality of parenting between egg donation and IVF families with an early adolescent child, with the exception of mothers’ reports of the degree to which fathers share the parenting load. This suggests that the absence of a genetic link with the mother is not essential for the development of positive family relationships. It might be the 616

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case that the shared experience of egg donation and IVF mothers of a strong commitment to become a parent, coupled with the opportunity to carry and bear a child, might account for the lack of difference found between them. Some differences were found, however, between the egg donation and DI families. In egg donation families, mothers seemed to respond less sensitively to their child’s needs, compared with mothers in DI families. One possible explanation for these findings relates to the difference in the pattern of genetic relationships between egg donation families and DI families. In DI families, mothers are genetically related to their child, whereas in egg donation families they are not. In egg donation families, the fact that fathers share a genetic link with their child whereas mothers do not, might, for some egg donation mothers, be associated with a degree of anxiety, which might interfere with their ability to respond to their child’s needs. However, it must be borne in mind that the mean difference between the egg donation and DI mothers on this variable represented only 1 point on a 4-point scale (i.e., between “average” and “above average” for sensitive responding), suggesting that egg donation mothers were still functioning well. Donor insemination mothers were also more likely to be emotionally over-involved with their child compared with egg donation mothers. It has been suggested that in DI families, in which the mother is the only parent with a genetic bond with the child, mothers might feel that they have a special relationship with the child (28). Such feelings might render some DI mothers more vulnerable to becoming emotionally over-involved with their child. It is important to point out, however, that the level of over-involvement found among DI mothers was not high enough to be considered problematic for parent– child relationships and the child’s psychological well-being. Interestingly, DI children reported more frequent and/or more serious incidences of bullying than did egg donation children. It might be the case that having a mother who is more likely to be over-involved might render children more vulnerable to negative reactions from their peers. Although DI mothers did not report any such difficulties, it is not uncommon for children not to tell their parents that they have been bullied. Interestingly, egg donation mothers reported their partners to be less reliable and less likely to share the parenting load than did DI mothers. Egg donation mothers’ anxieties about the lack of a genetic link with their child, coupled with their strong desire to have a child, might result in them feeling more inclined to take the major parenting load. In addition, the lack of a genetic tie between the father and child in DI families might mean that DI fathers make more effort to be involved in parenting than fathers who are genetically related to their children. It might also be the case that DI mothers are prone to present their partner’s involvement in parenting in a more positive light, which might further enhance the difference in egg donation and DI mothers’ reports of their partner’s contribution to parenting. Vol. 85, No. 3, March 2006

The children conceived by egg donation showed no evidence of psychological problems, as assessed by both interview and questionnaire measures. In addition, with the exception of the higher levels of bullying, reported by DI children, there were no group differences in the children’s reports of peer relationships or adjustment at school. It is noteworthy that there was no evidence of psychological or marital problems among parents in any of the family types, as assessed by self-report measures of anxiety, depression, and marital state. Interestingly, however, among the gamete donation families, marital breakdown seemed to be less common among the egg donation parents compared with DI parents, although this did not reach statistical significance. This reflected an absence of separation among the egg donation parents. It might be that certain aspects of egg donation that differ from DI might enhance marital stability. Although neither egg donation nor DI is a cure for infertility, the opportunity for egg donation mothers to share a biological link with their child (through pregnancy and childbirth) can, in some cases, help egg donation mothers overcome the anguish of infertility and re-establish their identity as that of a mother (11). This might reduce the potential negative effects of the experience of infertility on the marital relationship. In contrast, DI fathers often play a much less significant role in the journey to parenthood. Not only do DI fathers lack any biological link with their child, but there is also evidence that some clinics provide DI treatment to mothers without any involvement of the father in the process (32, 33). Thus, in DI there is an increased risk of some fathers feeling alienated from the parenting process, which, once the child has been born, might be further increased. It is possible that the alienation experienced by some DI fathers might lead to marital difficulties and, ultimately, the breakdown of the marital relationship. One limitation of the present study relates to the relatively small sample size of egg donation families. In the first phase of the present study, conducted in the early 1990s, all parents of a 3– 8-year-old egg donation child at participating clinics across the UK were asked to participate in the research. As egg donation had been practiced in the UK for only approximately 5 years, the number of available egg donation children who matched the age criteria for the study was therefore limited. An initial response rate of 81% was obtained, which was high for a study of such families. Thus, the families were originally recruited from a representative sample of egg donation families. In the present investigation, 17 of the original families took part. Two of the families could not be traced, and the remaining two declined to participate owing to concerns about secrecy. Thus, the final response rate for the follow-up study of egg donation families was 84%, which is higher than would be expected for a study of this kind. However, it is possible that the low statistical power associated with the Fertility and Sterility姞

small sample size means that significant differences between the family types remain undetected. Any study in which self-report methods and minority groups are used might be prone to the effect of social desirability bias, whereby parents attempt to present themselves and their children in the most positive light. Egg donation and DI families might be particularly at risk of this, owing to the stigma associated with the use of donated gametes to have a child and, consequently, the view that these families are “not normal.” One method used to address this problem is the use of multiple measures (standardized interviews and questionnaires) and multiple respondents (mothers and children). In addition, the high response rates attained, particularly for the gamete donation families, who are often more reluctant to take part in research owing to concerns about confidentiality, suggest that the low incidence of adjustment problems among the egg donation children cannot based on the assumption that those parents and children who were experiencing problems had withdrawn from the study. One researcher interviewed all the egg donation families, creating a possible risk of researcher bias. However, a proportion of the interviews were rated by a second trained researcher, and satisfactory interrater reliabilities were found (see Measures section in Materials and Methods). It is noteworthy that only 4 of the egg donation children were aware of their donor origins. Similarly, among the DI children, only 2 had been told. In contrast, 26 of the IVF children had been informed about the way in which they were conceived. In assisted reproductive families, in which both parents were genetically related to the child, parents were more likely to be open with their child about the method of his or her conception. The high level of nondisclosure among egg donation parents suggests that they are just as likely as DI parents to experience some degree of anxiety about their child’s donor origins and, therefore, just as inclined to feel the need to continue to conceal this fact as the child grows up. This goes some way to confirm the view that, like DI parents, egg donation parents experience a degree of social stigma surrounding the way they conceived their child (34). The biological link egg donation mothers share with their child through pregnancy did not make mothers more likely to tell their child about his or her donor origins as the child approached adolescence. For the majority of egg donation mothers, the reason for their decision not to tell their 12year-old child had not changed since the first phase of the study (35); it stemmed from a strong belief that it would be more harmful than beneficial for their child to learn about his/her donor origins. Despite egg donation parents’ decision to opt for nondisclosure, early adolescent egg donation children seem to be functioning well, suggesting that the secrecy surrounding the circumstances of their conception and the lack of a genetic 617

link with their mother was not exerting strong negative effects on the children’s psychological well-being or on family relationships in general. Nevertheless, nondisclosure to the child is not necessarily the best option for egg donation parents. The fact that nearly three quarters of the parents had told other people about the egg donation (16) creates a situation in which there is a high risk that the child will discover the truth about his/her donor origins from someone other than the parents. In addition, the growing use of genetic testing in medicine increases the risk that egg donation children will find out about the way in which they were conceived from medical professionals rather than their parents. It remains to be seen how children conceived by egg donation fare as they grow up. Research on adoption has shown that adopted children are more likely to react positively to the knowledge of their adoption if parents begin to introduce the information early on in the child’s life (36). Findings from two recent studies suggest that the same might be true for DI children. More DI-conceived people who had found out about the nature of their conception in late childhood or adulthood reported feelings of hostility and distrust toward their parents (37). In contrast, a small investigation of those who had been told in early childhood found the children to be generally accepting of this information (38). Egg donation children might be more likely to accept and successfully assimilate information about their donor origins if parents begin this discussion with them when they are young. REFERENCES 1. Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renou P. The establishment and maintenance of pregnancy using in vitro fertilisation and embryo donation in a patient with primary ovarian failure. Nature 1984;307:174 –5. 2. Trounson A, Leeton J, Besanka M, Wood C, Conti A. Pregnancy established in an infertile patient after transfer of a donated embryo fertilised in vitro. Br Med J 1983;286:835– 8. 3. Burns LH. An exploratory study of perceptions of parenting after infertility. Fam Systems Med 1990;8:177– 89. 4. van Balen F. Development of IVF children. Dev Rev 1998;18:30 – 46. 5. Baran A, Pannor R. Lethal secrets. 2nd ed. New York: Amistad, 1993. 6. Daniels K, Taylor K. Secrecy and openness in donor insemination. Politics Life Sci 1993;12:155–70. 7. Landau R. Secrecy, anonymity, and deception in donor insemination: a genetic, psycho-social and ethical critique. Soc Work Health Care 1998;28:75– 89. 8. Bok S. Secrets. New York: Pantheon, 1982. 9. De Paulo BM. Nonverbal behaviour and self-presentation. Psychol Bull 1992;111:203– 43. 10. Papp P. The worm in the bud: secrets between parents and children. In: Imber-Black E, ed. Secrets in families and family therapy. New York: Norton, 1993;66 – 85. 11. Raoul-Duval A, Letur-Konirsch H, Frydman R. Anonymous oocyte donation: a psychological study of recipients, donors and children. Hum Reprod 1992;7:51– 4. 12. Brodzinsky DM, Pinderhughes E. Parenting and child development in adoptive families. In: Bornstein M, ed. Handbook of parenting. 2nd ed (vol 1). Mahwah, NJ: Lawrence Erlbaum Associates, 2002:279 –313. 13. Brodzinsky DM, Smith DW, Brodzinsky AB. Children’s adjustment to adoption. Developmental and clinical issues. London: Sage Publications, 1998.

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