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Factors related to preferences in gamete donor sources
FERTILITY AND STERILITY
Vol. 63, No.3, March 1995
Printed on acid-free paper in U. S. A.
Copyright" 1995 American Society for Reproductive Medicine
Factors related to preferences in gamete donor sources
Andrea Mechanick Braverman, Ph.D.*t:J: Stephen L. Corson, M.D.§ Pennsylvania Reproductive Associates, and Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
Objective: To survey fertile and infertile individuals concerning attitudes about donor insemination and ovum donation and to analyze whether gender, experience with infertility, and religion influences: [1] preference for choosing gamete donor over adoption or child-free living; [2] choice of selecting a known or anonymous donor; or [3] choice of disclosure or nondisclosure to any offspring. Design: Patients in an infertility clinic and obstetrics and gynecology practice were asked to complete surveys. Participants: Three hundred nineteen individuals who completed surveys. Main Outcome Measures: A 14-item questionnaire (created for this study) with a demographic information section. Results: No gender differences were observed for preference to use donor gametes, to adopt, or to live child free within the infertility group. In the obstetrics and gynecology group, men preferred adoption more than women and were less likely to use a donor. Choice of whether to use a donor, which donor source, and whether to disclose the use of a donor was influenced by gender, experience with infertility, and religion. Conclusions: Gender, experience with infertility, and religion influence an individual's choice in family building options as well as what information will be shared with the child. There is a wider acceptance of using known donor sources than has heretofore been seen and these options should be explored. Fertil Steril 1995;63:543-9 Key Words: Ovum donors, sperm donors, psychological issues, disclosure
The practice of gamete donation has two different and distinct origins. Donor insemination began within the doctor's office through the use of an anonymous sperm donor recruited by the physician (1). Ovum donation evolved differently from sperm donation. The first case of ovum donation used an anonymous donor, but, in subsequent clinical practice, known donors, such as a sister or a friend, be-
Received March 18, 1994; revised and accepted September 29, 1994. * Department of Psychiatry, Pennsylvania Hospital, University of Pennsylvania School of Medicine. t Pennsylvania Reproductive Associates. :/: Reprint requests: Andrea Mechanick Braverman, Ph.D., Pennsylvania Hospital, Spruce Building, Room 786, 8th and Spruce Streets, Philadelphia, Pennsylvania 19107 (FAX: 215829-7210). § Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania School of Medicine. Vol. 63, No.3, March 1995
came common (1-3). It was the advent of ovum donation that began to raise questions about the assumptions that had traditionally accompanied donor insemination. There have not been any studies in the field of third party reproduction and nonbiologic parenting that have addressed the attitudes regarding the reproductive technologies for both infertile and fertile subjects. Nor have there been studies to look at individual's or couple's preferences regarding reproductive technologies, adoption, and child-free living; no studies have chosen to look specifically at whether couples would choose anonymous or known donors if they had the choice. Studies looking at the choice of disclosure or nondisclosure of the donor to the resulting offspring have been informative but are not conclusive, especially because there have not been any longitudinal prospective studies yet published (1-20).
Braverman and Corson Preferences in gamete donor sources
543
There has been a traditional bias within the medical community against disclosure about the child's donor origins. This may have reflected the fact that the donors were completely anonymous to the recipients and there was little or no information available on them. More important, anonymous donation was considered preferable, if not required, to protect the recipient father's relationship with the child, to avoid any potential negative psychological effects on the child, to deter any social stigmatization for any of the family members, and to circumvent any legal issues (1, 4, 5). Patients were not offered the choice of whether to use a known or anonymous donor and it was assumed that men would not want to use a known donor for psychological reasons. Changes were demonstrated clearly in the most recent survey of IVF programs of The American Fertility Society about the different choices available to their patients for gamete donation and, in particular, differences between the practice of sperm and ovum donation (6). Ninety percent of programs used paid sperm donors whereas 58% used paid ovum donors. However, 43% permitted use of brothers for sperm donation and 97% allowed sisters to be ovum donors. Friends and relatives were permitted as sperm donors in 32% of programs, but 76% allowed known ovum donors. Although most programs are offering both known and anonymous ovum donors, only about half of them also are offering these same choices for sperm donors. These programs are offering choices of donor source in a vacuum of information regarding what preferences the recipients might have. MATERIALS AND METHODS
One hundred fifty-seven women and 53 men from a Philadelphia infertility practice and 89 women and 20 men from a suburban obstetrics and gynecology (OB-GYN) practice completed surveys. Although some of the subjects were married couples, the surveys were not coded to identify couples who both answered the survey. The survey had an introductory paragraph stating the purpose of the study and then had 14 questions to be answered. The first seven questions inquired about the subject's choices should he or she be the infertile partner and the second seven questions inquired about the choices should the subject's partner be infertile (Table 1). If the subject were fertile, he or she was asked to imagine how he or she would feel for each question. 544
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Table 1
Questions for Sample
1. Imagine that the doctor has informed you that you have an
infertility problem that cannot be treated and that your only option is to use donor eggs/sperm. Adopt
Use donor eggs or sperm
Live child free
2. Imagine that you would choose to use donor eggs or sperm. Please rank how you would choose your donor:
anonymous donor
family member
friend
3. Do you have a sister or brother who could potentially donate eggs or sperm to you? 4. Do you have a mother/father who could potentially donate eggs or sperm to you?
yes
no
5. Do you have a friend who could potentially donate eggs or sperm to you?
__
yes
no
6. Imagine that you choose to use donor eggs or sperm. Would you be willing to accept eggs from: a) b) c)
Your mother or father: Your daughter or son: Your friend:
yes
no
yes yes
no no
7 . Would you ever plan to tell the child that you used an ovum or sperm donor?
__
yes
no
Analyses were performed within each of the four sample groups and within gender groups. Gender comparisons were performed and proportions were compared across groups using X2 statistics, Fisher's exact test, generalized exact tests, or X2 tests for trends in proportions, where appropriate. RESULTS
The results will be reported by describing first the demographics of the sample and then by the following group comparisons: [1] males and females within the infertility group; [2] males and females within the OB-GYN group; [3] all males and females by their experience with infertility; and [4] all males and females by religion. Demographics
A summary of the demographics is given in Table 2. There were no significant differences for mean
Preferences in gamete donor sources
Fertility and Sterility
Table 2
Demographic Composition of the Sample Controls
Age (y)* Marital statust Married Single Divorced Religion*:j: Catholic Protestant Jewish Other Experience with infertility:j: Friend Family
Men
Women
Men
Women
34.68 ± 6.89t
31.10 ± 7.01
34.08 ± 4.9
34.72 ± 5.9
84.2 10.5 5.3
76.7 19.8 3.5
98.1 1.9 0.0
92.2 5.8 2.0
21.1 63.2 5.2 10.5
37.4 37.4 2.4 22.9
53.9 11.5 13.5 21.2
46.7 19.7 14.5 19.1
10.5 5.3
18.6 15.1
15.4 15.4
19.9 10.6
* Significant control and infertile group differences P < 0.05.
ages for males in the infertile and OB-GYN groups, 34.1 and 34.7 years, respectively. The mean age for women in the infertility group was 34.7 years and the OB-GYN group was 31.1 years, which did significantly differ (P < 0.00001). There were significant differences between infertile and fertile groups for religious affiliation (P = 0.001). Gender Comparisons in the Infertility Practice
There were no significant differences in the rank ordering of fertility options (i.e., donor gametes, adoption, or child-free living) in the infertility sample by gender or by self or partner infertility factor, i.e., whether the infertility diagnosis was for self or partner. Table 3 illustrates the proportions of men and women willing to use different donors. When asked to imagine that they were willing to use a donor, males in the infertility group responded that they preferer,~;dly would choose anonymous donors (44%), family (42%), friend (4%), and no first choice (10%) and women would choose anonymous (43%), family (51%), friend (4%), and no first choice (3%); there was no difference by gender. If the spouse were infertile, there were significant differences between males and females (P = 0.05). Forty-seven percent of men in the infertility group Table 3 Gender Comparisons Among Known Donor Sources in the Infertility Group (Percentage Willing to Accept Donor Source)
Males (%) Females (%)
Parent donor
Sibling donor
Friend donor
41.2 60.4
66.7 45.2
56.9 66.9
Vol. 63, No.3, March 1995
Infertiles
t Values are means ± SD. :j: Values are percentages.
endorsed a preference for family members when selecting an ovum donor and 39% would select an anonymous ovum donor. For example, if the man's wife were infertile, he would prefer to use a sisterin-law rather than an anonymous donor. Anonymous sperm donors were preferred by 51 % of the women in the infertility group iftheir husband were infertile (P = 0.05) and 35% would choose a family member. The proportion of males from the infertility group who reported having a same sex sibling (P = 0.05) or live parent (P < 0.0001) was significantly higher than the women. An unexpectedly large proportion of males (41.2 %) from the infertility practice said they would accept donor sperm from their father. This was significantly <60.4% of the females who reported they would accept donor eggs from their mother (P = 0.02). A higher proportion of males (67%) than females (34%) reported they would accept donor gametes from a sibling (P = 0.01). There were gender differences within the infertility subject group in attitudes toward disclosure to a child who was conceived with donor gametes. Forty-seven percent of men and 72% of women reported that they would tell the child of its donor origin (P = 0.002). There was also a significant difference in proportions of women (70.3%) and men (54.0%) who would disclose to the child that their spouse had used a donor egg or sperm (P = 0.04). Gender Comparisons in the OB-GYN Practice
The proportions of men and women in the OBG YN practice choosing adoption, to live child free, Braverman and Corson
Preferences in gamete donor sources
545
or to use donor gametes significantly differed when the infertility problem was in themselves rather than with their partner (P = 0.03). Males were much more likely to choose to adopt (80% versus 48.9%) and much less likely to choose a donor (10% versus 37.5%). These choices also were observed when the infertility problem was imagined to lay with their spouse, 73.7% versus 48.3% and 15.8% versus 40.5%, respectively. Men in the OB-GYN group appeared more likely than females to choose an anonymous donor (55% versus 25%) if they had the infertility problem and women would more likely choose a family donor than men (61% versus 20%). Both genders would choose family and anonymous donors before they would choose a friend. Women in the OB-GYN group also indicated that they were much more willing to accept gametes from their mothers than men were from their fathers (P = 0.04). Men in the OBGYN practice (79%) did not indicate a greater willingness to disclose to a child that a donor sperm or egg was used than females (79%). For both genders, the attitude toward telling a child that a donor was used did not depend on whether sperm or eggs were donated. Experience with Infertility and Gender Comparisons
All women who had personal experience with infertility, regardless at which site their survey was collected, were much more likely to state a preference for an anonymous donor (44 %) compared with those with no self experience (24%) (P = 0.004). Sixty-nine percent of the subjects with family experience with infertility stated a preference for a family donor and only 20.7% of this group stated a preference for an anonymous donor. Self experience also had a similar effect of the woman choosing an anonymous donor if her spouse were infertile (P = 0.03). There appeared to be no relationship between any experience with infertility and the choice to tell a child that a donor was used. However, if experience was limited to only personal experience, there was a preference not to tell the child that a donor was used (P = 0.054). The impact of any infertility experience on all male subjects' choice of infertility option was much more dramatic than with women. Men with any experience with infertility were much more likely to indicate that they would use a donor (43 %) if faced with infertility than those with no such experience (15%) (P = 0.046), and similar findings were ob546
served when restricted to their own infertility experience (P = 0.018). Experience did not playa role in men's choice about disclosure. However, when comparing the OB-GYN group with the infertility group, there did appear to be significant differences in the proportions of men from the OB-GYN group (79%) and the infertility group (47%) willing to disclose to a child that they had used donor sperm or donor egg (82% versus 54%). All men and women from both locations were asked to indicate any donor choices that would be unacceptable for them. Anonymous donors were unacceptable to 12% of men and 11% of women. Family donors were unacceptable to 20% of men and 13% of women. Friend donors were unacceptable for 21 % of men and 16% of women. Comparisons Among Religious Affiliation
Religion was associated with the type of infertility option chosen for males (P = 0.03). Jewish respondents (75%) would opt for donor gametes for themselves more than Catholics (52%), Protestants (46%), or others (46%) (P = 0.049). These proportions were the same if the respondent was making the choice because his spouse was infertile. Gender differences interacted with religion for females only when she was making fertility choices for her spouse. The largest proportion (75%) opting for the use of donor sperm if their husband were infertile was among Jewish women (P = 0.054). There were no significant differences by religion if the women were choosing for themselves. Donor gametes were chosen as a first choice against childfree living or adoption in the following proportions: Catholic (53%), Protestant (39%), Jewish (58%), and other (46%). Significant differences (P < 0.02) were found among women who would wish to disclose to the child about the use of donor gametes: Catholic women (65 %), Jewish women (82%), Protestant women (74%), and other (90%).
DISCUSSION
Sperm and ovum donation have evolved differently, and these separate origins may have influenced the practice and preferences of donor gamete recipients. We also observed how the variables of gender, religion, and experience with infertility also may explain the choices couples make about such issues as donor preference and decision for disclosure and privacy. In this study, demographic discordancy between
Braverman and Corson Preferences in gamete donor sources
Fertility and Sterility
the OB-GYN and infertility practice populations by female age and religion may reflect the inherent differences in those populations seeking medical care. In addition, with respect to preference for adoption as a solution to infertility, patients in an infertility practice obviously have selected against that option, so that acquisition bias must be considered in comparing the two demographic groups. Surveys of programs providing donor gamete services show conflicting choices regarding preference for known or anonymous donor gametes. Sauer and Paulson (6) surveyed 51 ovum donor programs and found that 53 % stated that both anonymous and known donors were available but 29% of these programs provided only anonymous donors whereas 18% used only known donors. Braverman et al. (7) surveyed 82 programs and found that sibling donors were allowed in 97% of ovum donor programs and 43% of donor insemination programs. Similar disparity was found for relative-friend as donor with 76% of ovum donor and 32% of donor insemination programs. The American Fertility Society explicitly recommends the use of anonymous donors for oocyte gamete recipients. However, almost all programs appear to endorse the use of known donors (8). Pettee and Weckstein (9) noted a preference for known donors for couples who had successfully participated in ovum donation. Sauer et al. (10) also found acceptability for sibling donors for ovum donor recipient couples but found that recipients rejected the use of sibling donors in donor insemination. Other studies have failed to distinguish whether anonymous or known donor has any effect on their outcomes (11, 12). Anonymous gamete donation generated a selffulfilling prophecy because patients were not offered the option of using known donors. We felt comfortable with anonymous donors because that was our only experience and we saw that families coped successfully. There was an underlying bias towards using anonymous situations. Other factors such as psychosocial impact on the infertile male, stigmatization of the child, and societal acceptance influenced the choice to use anonymous donors and to keep their use secret (5, 13-15). The choice of whether to use a known or anonymous donor also can be seen as part of a larger decision about whether to disclose to the child that he or she was conceived through donor gametes. This has been discussed as the choice between disclosure and privacy. Little is known about what choices individuals make about the type of donor they would Vol. 63, No.3, March 1995
select if there was truly a variety of donors available. Attitudes about the use of donor gametes and about the issue of disclosure and privacy differ among medical professionals. Leiblum and Hamkins (16) surveyed physicians about whether patients should disclose to any offspring the use of donor sperm and found that 56% advocated that the child did not need to be told, 22% endorsed disclosing to the child, and 21 % were neutral. Expert opinions also reflect the split between those choosing disclosure (13, 14) and those who acknowledge the choice of privacy (17, 18). Several studies have looked at the disclosure and privacy issue among couples who have conceived already through donor sperm (5, 17, 19). Schover et al. (19) demonstrated a very strong trend toward privacy, with 64% of women and 80% of men choosing total secrecy. Klock and Maier (18) demonstrated also that the majority of couples are choosing privacy and that those couples who did disclose the use of a donor to an outside person would not do so again. These studies have examined the disclosure issue solely from the viewpoint of how subjects feel if it is the male who is infertile. Men appear to be less willing to disclose the use of donor gametes independent of whether donor sperm or donor egg is used. There have been many studies that have shown that men are not inclined toward disclosure (11-15). There has been speculation that this is because a man will feel stigmatized by his infertility, which may affect his sense of selfesteem and have other negative psychosocial consequences, and that men need to protect their relationship to the child because they will have no direct biologic link. Our study found that gender differences exist for disclosure regardless of whether there are eggs or sperm being donated. Women appear to be more willing to disclose the use of donor gametes independent of whether it is donor egg or sperm used. This challenges the notion that men choose not to disclose only because it may be damaging to their "male ego." Sensitivity to embarrassment about his infertility, fear of stigmatization, concerns about parent-child attachment, and lack of any biologic input may indeed contribute to the male's preference for nondisclosure. However, gender differences about disclosure may reflect two different styles of approach to all choices encountered in donor gametes. The male preference for nondisclosure also may have other origins in light of the fact that men stated an equal preference for anonymous and fam-
Braverman and Corson Preferences in gamete donor sources
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ily donors. Men, because they plan not to disclose to the child, may wish for a known family donor because they will have all the donor's information to pass on to the child without the need to directly disclose the donor's involvement. Women may be more comfortable using anonymous donors because they are more likely to disclose the fact that a donor egg had been used and the anonymity allows for disclosure without any direct complication of contact with the egg donor. Thus, for a proportion of men, the choice of nondisclosure may be influenced by their choice of donor. There appears to be social acceptance for donor gametes and, in particular, for known donors. These results are contrary to findings in previous studies (20, 21). Remarkably, in our study sample, <20% of the male and female groups rejected the various known donor situations as unacceptable. Furthermore, women and men from the infertile group chose donors in the same proportions should the infertility problem lie with themselves; preferences were closely tied between using anonymous and family donors. These proportions changed should the infertility lie with their spouses. In this situation, men prefer known family donors whereas women prefer anonymous donors. Women's preference for anonymous donors in this study may reflect the earlier speculation that women tend to protect their male partner through the use of an anonymous donor, fearing that a known donor would be too threatening to their partner. Because the woman would be able to contribute the gestation to the child, in the case of her own infertility, this may make using a family donor more appealing to the male partner. Gamete donation from a parent had greater acceptability than anticipated and showed gender differences. Over half (60%) of women stated and 41 % of men stated that they would accept donor gametes from their parents. However, males are reported being significantly more comfortable with sibling donation. Because the likelihood that a woman would have a mother who could donate eggs is small, this is not likely to open a new option for ovum donation programs. Religion also plays a role in choosing to use a donor and whether to disclose to a child his or her donor origins. Jewish men and women were most likely to opt to use a donor and Jewish men were less willing to disclose than other male religious groups. Catholic women were least likely to disclose the use of a donor. Experience with infertility created more comfort 548
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with the use of donor gametes. Men were much more likely to seek a donor if they had previous infertility experience, but this did not affect their choice not to disclose. For women, infertility experience meant a greater desire for an anonymous donor. If restricted to personal experience with infertility, disclosure choice was affected in favor of not disclosing to the child. As seen in earlier research, experience and the reality of the situation may have a profound impact on the choices we make. Couples who no longer can contribute genetically to their child may be more attuned to the very complex choices and issues that their family may face as a result of using a donor. Furthermore, the genetic composition may be less important to them than the wish to parent. The role of the psychosocial parent may be more important to them than the genetic role. Infertility experience forces the individual to confront his or her own feelings and values about parenting and family. Through this process, the choices about the type of donor and the issue of disclosure may undergo tremendous change compared with abstract contemplation. The results ofthis study give rise to some practical clinical considerations. First, ovum donor programs should explore pilot projects in which couples can be given informed choice of anonymous or known donors. There is no evidence that known or anonymous donation creates more psychosocial problems, although there is tremendous need for longitudinal research following these families. Second, our own level of discomfort with potential known donors such as parents or siblings needs to be examined particularly with regard to our inclusion-exclusion criteria. Cultural differences, as well as experience, may playa critical role in allowing these less practiced donor options to become available. Each patient and couple brings his/her unique situation and values into the decision of whether to use donor gametes and, if so, what type of donor to use. Individual counseling can playa critical role in helping each individual carefully consider the advantages and disadvantages of each option.
REFERENCES 1. Klock SC. Psychological aspects of donor insemination. In:
Greenfeld DA, editor. Infertility and reproductive medicine clinics of North America: psychological issues in infertility. Philadelphia: W.B. Saunders Co., 1993:455-70. 2. Schover LR. Psychological aspects of oocyte donation. In: Greenfeld DA, editor. Infertility and reproductive medicine
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3.
4. 5. 6.
7.
8. 9. 10.
11.
clinics of North America: psychological issues in infertility. Philadelphia: W.B. Saunders Co., 1993:483-502. Leeton J, Chan LK, Trounson A, Harman J. Pregnancy established in an infertile patient after transfer of an embryo fertilized in vitro where the oocyte was donated by the sister of the recipient. J In Vitro Fert Embryo Transf 1986;3:379-82. Robertson JA. Ethical and legal issues in human egg donation. Fertil Steril 1989;52:353-63. Clayton C, Kovacs G. AID offspring: initial follow-up study of 50 couples. Med J Aust 1982;1:338-9. Sauer MV, Paulson RJ. Understanding the current status of oocyte donation in the United States: what's really going on out there? Fertil Steril 1992;58:16-8. Braverman AM, Ovum Donor Task Force of the Psychological Special Interests Group of The American Fertility Society. Survey results on the current practice of ovum donation programs. Fertil Steril 1993;59:1216-20. The American Fertility Society. Guidelines for gamete donation: 1993. Fertil Steril 1993;1:lS-9S. Pettee D, Weckstein LN. A survey of parent attitudes toward oocyte donation. Hum Reprod 1993;8:1963-5. Sauer MV, Rodi lA, Scrooc M, Bustillo M, Buster JE. Survey of attitudes regarding the use of siblings for gamete donation. Fertil Steril1988;49:721-2. Mahlstedt PP, Greenfeld DA. Assisted reproductive technology with donor gametes: the need for patient preparation. Fertil Steril1989;52:908-14.
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12. Berger DM, Eisen A, Shuber J, Doody KF. Psychological patterns in donor insemination couples. Can J Psychiatry 1986;31:818-23. 13. Noble E. Having your baby by donor insemination. Boston: Houghton Mifflin Company, 1987. 14. Baran A, Pannor R. Lethal secrets: the psychology of donor insemination. New York: Amistad Press, Inc., 1993. 15. Manuel C, Chevret M, Czyba J. Handling of secrecy by AID couples. In: David G, Price W, editors. Human artificial insemination and semen preservation. New York: Plenum Press, 1980:419. 16. Leiblum SR, Hamkins SE. To tell or not to tell: attitudes of reproductive endocrinologist concerning disclosure to offspring of conception via assisted insemination by donor. J Psychosom Obstet Gynaecol1992;13:267-75. 17. Nachtigall RD. Secrecy: an unresolved issue in the practice of donor insemination. Am J Obstet Gynecol 1993;168: 1846-51. 18. Klock SC, Maier D. Psychological factors related to donor insemination. Fertil Steril 1991;56:489-95. 19. Schover LR, Collins RL, Richards S. Psychological aspects of donor insemination: evaluation and follow-up ofrecipient couples. Fertil Steril 1992;57:583-90. 20. Matteson R, Terranova G. Social acceptance of new techniques of child conception. J Soc Psychol 1977;101:225-9. 21. Dunn P, Ryan I, O'Brien K. College students' acceptance of adoption and five alternative fertilization techniques. J Sex Res 1988;24:282-7.
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Vol. 63, No.3, March 1995
Printed on acid-free paper in U. S. A.
Copyright" 1995 American Society for Reproductive Medicine
Factors related to preferences in gamete donor sources
Andrea Mechanick Braverman, Ph.D.*t:J: Stephen L. Corson, M.D.§ Pennsylvania Reproductive Associates, and Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
Objective: To survey fertile and infertile individuals concerning attitudes about donor insemination and ovum donation and to analyze whether gender, experience with infertility, and religion influences: [1] preference for choosing gamete donor over adoption or child-free living; [2] choice of selecting a known or anonymous donor; or [3] choice of disclosure or nondisclosure to any offspring. Design: Patients in an infertility clinic and obstetrics and gynecology practice were asked to complete surveys. Participants: Three hundred nineteen individuals who completed surveys. Main Outcome Measures: A 14-item questionnaire (created for this study) with a demographic information section. Results: No gender differences were observed for preference to use donor gametes, to adopt, or to live child free within the infertility group. In the obstetrics and gynecology group, men preferred adoption more than women and were less likely to use a donor. Choice of whether to use a donor, which donor source, and whether to disclose the use of a donor was influenced by gender, experience with infertility, and religion. Conclusions: Gender, experience with infertility, and religion influence an individual's choice in family building options as well as what information will be shared with the child. There is a wider acceptance of using known donor sources than has heretofore been seen and these options should be explored. Fertil Steril 1995;63:543-9 Key Words: Ovum donors, sperm donors, psychological issues, disclosure
The practice of gamete donation has two different and distinct origins. Donor insemination began within the doctor's office through the use of an anonymous sperm donor recruited by the physician (1). Ovum donation evolved differently from sperm donation. The first case of ovum donation used an anonymous donor, but, in subsequent clinical practice, known donors, such as a sister or a friend, be-
Received March 18, 1994; revised and accepted September 29, 1994. * Department of Psychiatry, Pennsylvania Hospital, University of Pennsylvania School of Medicine. t Pennsylvania Reproductive Associates. :/: Reprint requests: Andrea Mechanick Braverman, Ph.D., Pennsylvania Hospital, Spruce Building, Room 786, 8th and Spruce Streets, Philadelphia, Pennsylvania 19107 (FAX: 215829-7210). § Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania School of Medicine. Vol. 63, No.3, March 1995
came common (1-3). It was the advent of ovum donation that began to raise questions about the assumptions that had traditionally accompanied donor insemination. There have not been any studies in the field of third party reproduction and nonbiologic parenting that have addressed the attitudes regarding the reproductive technologies for both infertile and fertile subjects. Nor have there been studies to look at individual's or couple's preferences regarding reproductive technologies, adoption, and child-free living; no studies have chosen to look specifically at whether couples would choose anonymous or known donors if they had the choice. Studies looking at the choice of disclosure or nondisclosure of the donor to the resulting offspring have been informative but are not conclusive, especially because there have not been any longitudinal prospective studies yet published (1-20).
Braverman and Corson Preferences in gamete donor sources
543
There has been a traditional bias within the medical community against disclosure about the child's donor origins. This may have reflected the fact that the donors were completely anonymous to the recipients and there was little or no information available on them. More important, anonymous donation was considered preferable, if not required, to protect the recipient father's relationship with the child, to avoid any potential negative psychological effects on the child, to deter any social stigmatization for any of the family members, and to circumvent any legal issues (1, 4, 5). Patients were not offered the choice of whether to use a known or anonymous donor and it was assumed that men would not want to use a known donor for psychological reasons. Changes were demonstrated clearly in the most recent survey of IVF programs of The American Fertility Society about the different choices available to their patients for gamete donation and, in particular, differences between the practice of sperm and ovum donation (6). Ninety percent of programs used paid sperm donors whereas 58% used paid ovum donors. However, 43% permitted use of brothers for sperm donation and 97% allowed sisters to be ovum donors. Friends and relatives were permitted as sperm donors in 32% of programs, but 76% allowed known ovum donors. Although most programs are offering both known and anonymous ovum donors, only about half of them also are offering these same choices for sperm donors. These programs are offering choices of donor source in a vacuum of information regarding what preferences the recipients might have. MATERIALS AND METHODS
One hundred fifty-seven women and 53 men from a Philadelphia infertility practice and 89 women and 20 men from a suburban obstetrics and gynecology (OB-GYN) practice completed surveys. Although some of the subjects were married couples, the surveys were not coded to identify couples who both answered the survey. The survey had an introductory paragraph stating the purpose of the study and then had 14 questions to be answered. The first seven questions inquired about the subject's choices should he or she be the infertile partner and the second seven questions inquired about the choices should the subject's partner be infertile (Table 1). If the subject were fertile, he or she was asked to imagine how he or she would feel for each question. 544
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Table 1
Questions for Sample
1. Imagine that the doctor has informed you that you have an
infertility problem that cannot be treated and that your only option is to use donor eggs/sperm. Adopt
Use donor eggs or sperm
Live child free
2. Imagine that you would choose to use donor eggs or sperm. Please rank how you would choose your donor:
anonymous donor
family member
friend
3. Do you have a sister or brother who could potentially donate eggs or sperm to you? 4. Do you have a mother/father who could potentially donate eggs or sperm to you?
yes
no
5. Do you have a friend who could potentially donate eggs or sperm to you?
__
yes
no
6. Imagine that you choose to use donor eggs or sperm. Would you be willing to accept eggs from: a) b) c)
Your mother or father: Your daughter or son: Your friend:
yes
no
yes yes
no no
7 . Would you ever plan to tell the child that you used an ovum or sperm donor?
__
yes
no
Analyses were performed within each of the four sample groups and within gender groups. Gender comparisons were performed and proportions were compared across groups using X2 statistics, Fisher's exact test, generalized exact tests, or X2 tests for trends in proportions, where appropriate. RESULTS
The results will be reported by describing first the demographics of the sample and then by the following group comparisons: [1] males and females within the infertility group; [2] males and females within the OB-GYN group; [3] all males and females by their experience with infertility; and [4] all males and females by religion. Demographics
A summary of the demographics is given in Table 2. There were no significant differences for mean
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Table 2
Demographic Composition of the Sample Controls
Age (y)* Marital statust Married Single Divorced Religion*:j: Catholic Protestant Jewish Other Experience with infertility:j: Friend Family
Men
Women
Men
Women
34.68 ± 6.89t
31.10 ± 7.01
34.08 ± 4.9
34.72 ± 5.9
84.2 10.5 5.3
76.7 19.8 3.5
98.1 1.9 0.0
92.2 5.8 2.0
21.1 63.2 5.2 10.5
37.4 37.4 2.4 22.9
53.9 11.5 13.5 21.2
46.7 19.7 14.5 19.1
10.5 5.3
18.6 15.1
15.4 15.4
19.9 10.6
* Significant control and infertile group differences P < 0.05.
ages for males in the infertile and OB-GYN groups, 34.1 and 34.7 years, respectively. The mean age for women in the infertility group was 34.7 years and the OB-GYN group was 31.1 years, which did significantly differ (P < 0.00001). There were significant differences between infertile and fertile groups for religious affiliation (P = 0.001). Gender Comparisons in the Infertility Practice
There were no significant differences in the rank ordering of fertility options (i.e., donor gametes, adoption, or child-free living) in the infertility sample by gender or by self or partner infertility factor, i.e., whether the infertility diagnosis was for self or partner. Table 3 illustrates the proportions of men and women willing to use different donors. When asked to imagine that they were willing to use a donor, males in the infertility group responded that they preferer,~;dly would choose anonymous donors (44%), family (42%), friend (4%), and no first choice (10%) and women would choose anonymous (43%), family (51%), friend (4%), and no first choice (3%); there was no difference by gender. If the spouse were infertile, there were significant differences between males and females (P = 0.05). Forty-seven percent of men in the infertility group Table 3 Gender Comparisons Among Known Donor Sources in the Infertility Group (Percentage Willing to Accept Donor Source)
Males (%) Females (%)
Parent donor
Sibling donor
Friend donor
41.2 60.4
66.7 45.2
56.9 66.9
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Infertiles
t Values are means ± SD. :j: Values are percentages.
endorsed a preference for family members when selecting an ovum donor and 39% would select an anonymous ovum donor. For example, if the man's wife were infertile, he would prefer to use a sisterin-law rather than an anonymous donor. Anonymous sperm donors were preferred by 51 % of the women in the infertility group iftheir husband were infertile (P = 0.05) and 35% would choose a family member. The proportion of males from the infertility group who reported having a same sex sibling (P = 0.05) or live parent (P < 0.0001) was significantly higher than the women. An unexpectedly large proportion of males (41.2 %) from the infertility practice said they would accept donor sperm from their father. This was significantly <60.4% of the females who reported they would accept donor eggs from their mother (P = 0.02). A higher proportion of males (67%) than females (34%) reported they would accept donor gametes from a sibling (P = 0.01). There were gender differences within the infertility subject group in attitudes toward disclosure to a child who was conceived with donor gametes. Forty-seven percent of men and 72% of women reported that they would tell the child of its donor origin (P = 0.002). There was also a significant difference in proportions of women (70.3%) and men (54.0%) who would disclose to the child that their spouse had used a donor egg or sperm (P = 0.04). Gender Comparisons in the OB-GYN Practice
The proportions of men and women in the OBG YN practice choosing adoption, to live child free, Braverman and Corson
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or to use donor gametes significantly differed when the infertility problem was in themselves rather than with their partner (P = 0.03). Males were much more likely to choose to adopt (80% versus 48.9%) and much less likely to choose a donor (10% versus 37.5%). These choices also were observed when the infertility problem was imagined to lay with their spouse, 73.7% versus 48.3% and 15.8% versus 40.5%, respectively. Men in the OB-GYN group appeared more likely than females to choose an anonymous donor (55% versus 25%) if they had the infertility problem and women would more likely choose a family donor than men (61% versus 20%). Both genders would choose family and anonymous donors before they would choose a friend. Women in the OB-GYN group also indicated that they were much more willing to accept gametes from their mothers than men were from their fathers (P = 0.04). Men in the OBGYN practice (79%) did not indicate a greater willingness to disclose to a child that a donor sperm or egg was used than females (79%). For both genders, the attitude toward telling a child that a donor was used did not depend on whether sperm or eggs were donated. Experience with Infertility and Gender Comparisons
All women who had personal experience with infertility, regardless at which site their survey was collected, were much more likely to state a preference for an anonymous donor (44 %) compared with those with no self experience (24%) (P = 0.004). Sixty-nine percent of the subjects with family experience with infertility stated a preference for a family donor and only 20.7% of this group stated a preference for an anonymous donor. Self experience also had a similar effect of the woman choosing an anonymous donor if her spouse were infertile (P = 0.03). There appeared to be no relationship between any experience with infertility and the choice to tell a child that a donor was used. However, if experience was limited to only personal experience, there was a preference not to tell the child that a donor was used (P = 0.054). The impact of any infertility experience on all male subjects' choice of infertility option was much more dramatic than with women. Men with any experience with infertility were much more likely to indicate that they would use a donor (43 %) if faced with infertility than those with no such experience (15%) (P = 0.046), and similar findings were ob546
served when restricted to their own infertility experience (P = 0.018). Experience did not playa role in men's choice about disclosure. However, when comparing the OB-GYN group with the infertility group, there did appear to be significant differences in the proportions of men from the OB-GYN group (79%) and the infertility group (47%) willing to disclose to a child that they had used donor sperm or donor egg (82% versus 54%). All men and women from both locations were asked to indicate any donor choices that would be unacceptable for them. Anonymous donors were unacceptable to 12% of men and 11% of women. Family donors were unacceptable to 20% of men and 13% of women. Friend donors were unacceptable for 21 % of men and 16% of women. Comparisons Among Religious Affiliation
Religion was associated with the type of infertility option chosen for males (P = 0.03). Jewish respondents (75%) would opt for donor gametes for themselves more than Catholics (52%), Protestants (46%), or others (46%) (P = 0.049). These proportions were the same if the respondent was making the choice because his spouse was infertile. Gender differences interacted with religion for females only when she was making fertility choices for her spouse. The largest proportion (75%) opting for the use of donor sperm if their husband were infertile was among Jewish women (P = 0.054). There were no significant differences by religion if the women were choosing for themselves. Donor gametes were chosen as a first choice against childfree living or adoption in the following proportions: Catholic (53%), Protestant (39%), Jewish (58%), and other (46%). Significant differences (P < 0.02) were found among women who would wish to disclose to the child about the use of donor gametes: Catholic women (65 %), Jewish women (82%), Protestant women (74%), and other (90%).
DISCUSSION
Sperm and ovum donation have evolved differently, and these separate origins may have influenced the practice and preferences of donor gamete recipients. We also observed how the variables of gender, religion, and experience with infertility also may explain the choices couples make about such issues as donor preference and decision for disclosure and privacy. In this study, demographic discordancy between
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the OB-GYN and infertility practice populations by female age and religion may reflect the inherent differences in those populations seeking medical care. In addition, with respect to preference for adoption as a solution to infertility, patients in an infertility practice obviously have selected against that option, so that acquisition bias must be considered in comparing the two demographic groups. Surveys of programs providing donor gamete services show conflicting choices regarding preference for known or anonymous donor gametes. Sauer and Paulson (6) surveyed 51 ovum donor programs and found that 53 % stated that both anonymous and known donors were available but 29% of these programs provided only anonymous donors whereas 18% used only known donors. Braverman et al. (7) surveyed 82 programs and found that sibling donors were allowed in 97% of ovum donor programs and 43% of donor insemination programs. Similar disparity was found for relative-friend as donor with 76% of ovum donor and 32% of donor insemination programs. The American Fertility Society explicitly recommends the use of anonymous donors for oocyte gamete recipients. However, almost all programs appear to endorse the use of known donors (8). Pettee and Weckstein (9) noted a preference for known donors for couples who had successfully participated in ovum donation. Sauer et al. (10) also found acceptability for sibling donors for ovum donor recipient couples but found that recipients rejected the use of sibling donors in donor insemination. Other studies have failed to distinguish whether anonymous or known donor has any effect on their outcomes (11, 12). Anonymous gamete donation generated a selffulfilling prophecy because patients were not offered the option of using known donors. We felt comfortable with anonymous donors because that was our only experience and we saw that families coped successfully. There was an underlying bias towards using anonymous situations. Other factors such as psychosocial impact on the infertile male, stigmatization of the child, and societal acceptance influenced the choice to use anonymous donors and to keep their use secret (5, 13-15). The choice of whether to use a known or anonymous donor also can be seen as part of a larger decision about whether to disclose to the child that he or she was conceived through donor gametes. This has been discussed as the choice between disclosure and privacy. Little is known about what choices individuals make about the type of donor they would Vol. 63, No.3, March 1995
select if there was truly a variety of donors available. Attitudes about the use of donor gametes and about the issue of disclosure and privacy differ among medical professionals. Leiblum and Hamkins (16) surveyed physicians about whether patients should disclose to any offspring the use of donor sperm and found that 56% advocated that the child did not need to be told, 22% endorsed disclosing to the child, and 21 % were neutral. Expert opinions also reflect the split between those choosing disclosure (13, 14) and those who acknowledge the choice of privacy (17, 18). Several studies have looked at the disclosure and privacy issue among couples who have conceived already through donor sperm (5, 17, 19). Schover et al. (19) demonstrated a very strong trend toward privacy, with 64% of women and 80% of men choosing total secrecy. Klock and Maier (18) demonstrated also that the majority of couples are choosing privacy and that those couples who did disclose the use of a donor to an outside person would not do so again. These studies have examined the disclosure issue solely from the viewpoint of how subjects feel if it is the male who is infertile. Men appear to be less willing to disclose the use of donor gametes independent of whether donor sperm or donor egg is used. There have been many studies that have shown that men are not inclined toward disclosure (11-15). There has been speculation that this is because a man will feel stigmatized by his infertility, which may affect his sense of selfesteem and have other negative psychosocial consequences, and that men need to protect their relationship to the child because they will have no direct biologic link. Our study found that gender differences exist for disclosure regardless of whether there are eggs or sperm being donated. Women appear to be more willing to disclose the use of donor gametes independent of whether it is donor egg or sperm used. This challenges the notion that men choose not to disclose only because it may be damaging to their "male ego." Sensitivity to embarrassment about his infertility, fear of stigmatization, concerns about parent-child attachment, and lack of any biologic input may indeed contribute to the male's preference for nondisclosure. However, gender differences about disclosure may reflect two different styles of approach to all choices encountered in donor gametes. The male preference for nondisclosure also may have other origins in light of the fact that men stated an equal preference for anonymous and fam-
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ily donors. Men, because they plan not to disclose to the child, may wish for a known family donor because they will have all the donor's information to pass on to the child without the need to directly disclose the donor's involvement. Women may be more comfortable using anonymous donors because they are more likely to disclose the fact that a donor egg had been used and the anonymity allows for disclosure without any direct complication of contact with the egg donor. Thus, for a proportion of men, the choice of nondisclosure may be influenced by their choice of donor. There appears to be social acceptance for donor gametes and, in particular, for known donors. These results are contrary to findings in previous studies (20, 21). Remarkably, in our study sample, <20% of the male and female groups rejected the various known donor situations as unacceptable. Furthermore, women and men from the infertile group chose donors in the same proportions should the infertility problem lie with themselves; preferences were closely tied between using anonymous and family donors. These proportions changed should the infertility lie with their spouses. In this situation, men prefer known family donors whereas women prefer anonymous donors. Women's preference for anonymous donors in this study may reflect the earlier speculation that women tend to protect their male partner through the use of an anonymous donor, fearing that a known donor would be too threatening to their partner. Because the woman would be able to contribute the gestation to the child, in the case of her own infertility, this may make using a family donor more appealing to the male partner. Gamete donation from a parent had greater acceptability than anticipated and showed gender differences. Over half (60%) of women stated and 41 % of men stated that they would accept donor gametes from their parents. However, males are reported being significantly more comfortable with sibling donation. Because the likelihood that a woman would have a mother who could donate eggs is small, this is not likely to open a new option for ovum donation programs. Religion also plays a role in choosing to use a donor and whether to disclose to a child his or her donor origins. Jewish men and women were most likely to opt to use a donor and Jewish men were less willing to disclose than other male religious groups. Catholic women were least likely to disclose the use of a donor. Experience with infertility created more comfort 548
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with the use of donor gametes. Men were much more likely to seek a donor if they had previous infertility experience, but this did not affect their choice not to disclose. For women, infertility experience meant a greater desire for an anonymous donor. If restricted to personal experience with infertility, disclosure choice was affected in favor of not disclosing to the child. As seen in earlier research, experience and the reality of the situation may have a profound impact on the choices we make. Couples who no longer can contribute genetically to their child may be more attuned to the very complex choices and issues that their family may face as a result of using a donor. Furthermore, the genetic composition may be less important to them than the wish to parent. The role of the psychosocial parent may be more important to them than the genetic role. Infertility experience forces the individual to confront his or her own feelings and values about parenting and family. Through this process, the choices about the type of donor and the issue of disclosure may undergo tremendous change compared with abstract contemplation. The results ofthis study give rise to some practical clinical considerations. First, ovum donor programs should explore pilot projects in which couples can be given informed choice of anonymous or known donors. There is no evidence that known or anonymous donation creates more psychosocial problems, although there is tremendous need for longitudinal research following these families. Second, our own level of discomfort with potential known donors such as parents or siblings needs to be examined particularly with regard to our inclusion-exclusion criteria. Cultural differences, as well as experience, may playa critical role in allowing these less practiced donor options to become available. Each patient and couple brings his/her unique situation and values into the decision of whether to use donor gametes and, if so, what type of donor to use. Individual counseling can playa critical role in helping each individual carefully consider the advantages and disadvantages of each option.
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Greenfeld DA, editor. Infertility and reproductive medicine clinics of North America: psychological issues in infertility. Philadelphia: W.B. Saunders Co., 1993:455-70. 2. Schover LR. Psychological aspects of oocyte donation. In: Greenfeld DA, editor. Infertility and reproductive medicine
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clinics of North America: psychological issues in infertility. Philadelphia: W.B. Saunders Co., 1993:483-502. Leeton J, Chan LK, Trounson A, Harman J. Pregnancy established in an infertile patient after transfer of an embryo fertilized in vitro where the oocyte was donated by the sister of the recipient. J In Vitro Fert Embryo Transf 1986;3:379-82. Robertson JA. Ethical and legal issues in human egg donation. Fertil Steril 1989;52:353-63. Clayton C, Kovacs G. AID offspring: initial follow-up study of 50 couples. Med J Aust 1982;1:338-9. Sauer MV, Paulson RJ. Understanding the current status of oocyte donation in the United States: what's really going on out there? Fertil Steril 1992;58:16-8. Braverman AM, Ovum Donor Task Force of the Psychological Special Interests Group of The American Fertility Society. Survey results on the current practice of ovum donation programs. Fertil Steril 1993;59:1216-20. The American Fertility Society. Guidelines for gamete donation: 1993. Fertil Steril 1993;1:lS-9S. Pettee D, Weckstein LN. A survey of parent attitudes toward oocyte donation. Hum Reprod 1993;8:1963-5. Sauer MV, Rodi lA, Scrooc M, Bustillo M, Buster JE. Survey of attitudes regarding the use of siblings for gamete donation. Fertil Steril1988;49:721-2. Mahlstedt PP, Greenfeld DA. Assisted reproductive technology with donor gametes: the need for patient preparation. Fertil Steril1989;52:908-14.
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12. Berger DM, Eisen A, Shuber J, Doody KF. Psychological patterns in donor insemination couples. Can J Psychiatry 1986;31:818-23. 13. Noble E. Having your baby by donor insemination. Boston: Houghton Mifflin Company, 1987. 14. Baran A, Pannor R. Lethal secrets: the psychology of donor insemination. New York: Amistad Press, Inc., 1993. 15. Manuel C, Chevret M, Czyba J. Handling of secrecy by AID couples. In: David G, Price W, editors. Human artificial insemination and semen preservation. New York: Plenum Press, 1980:419. 16. Leiblum SR, Hamkins SE. To tell or not to tell: attitudes of reproductive endocrinologist concerning disclosure to offspring of conception via assisted insemination by donor. J Psychosom Obstet Gynaecol1992;13:267-75. 17. Nachtigall RD. Secrecy: an unresolved issue in the practice of donor insemination. Am J Obstet Gynecol 1993;168: 1846-51. 18. Klock SC, Maier D. Psychological factors related to donor insemination. Fertil Steril 1991;56:489-95. 19. Schover LR, Collins RL, Richards S. Psychological aspects of donor insemination: evaluation and follow-up ofrecipient couples. Fertil Steril 1992;57:583-90. 20. Matteson R, Terranova G. Social acceptance of new techniques of child conception. J Soc Psychol 1977;101:225-9. 21. Dunn P, Ryan I, O'Brien K. College students' acceptance of adoption and five alternative fertilization techniques. J Sex Res 1988;24:282-7.
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