Psychological factors related to donor insemination

FERTILITY AND STERILITY

Vol. 56, No.3, September 1991 Printed on acid-free paper in U.S.A.

Copyright e 1991 The American Fertility Society

Psychological factors related to donor insemination

Susan C. Klock, Ph.D. *tt Donald Maier, M.D.* University of Connecticut Health Center, Farmington, Connecticut

Objective: To survey a sample of couples who had completed therapeutic donor insemination (TDI) regarding several psychological variables. Design: Couples who had conceived through TDI in the past 7 years completed a retrospective survey. Participants: Thirty-five of seventy couples returned completed questionnaires. Measures: Demographic questionnaire, TDI, and confidentiality questionnaire (created for this study), Dyadic Adjustment Scale. Results: The majority of the subjects told at least one person about the TDI but 81% of subjects who told someone reported that, if they had to do it over again, they would tell no one. Eighty-six percent reported that they have not and will not tell the child. Time from diagnosis to beginning TDI was not correlated with marital adjustment after TDI. Overall, the couples reported average marital adjustment. For both men and women, the biggest concern was the genetic/medical history of the donor. Most couples did not have psychological counseling, but 39% thought it should be mandatory. Conclusions: Retrospectively, most couples regretted telling others about TDI. Most couples do not plan to tell the TDI child about its genetic origin. The major concern about TDI is the genetic and medical background of the donor. Psychological counseling should be available to couples unFertil Steril 56:489, 1991 dergoing TDI.

Therapeutic donor insemination (TDI) is a common treatment for male factor infertility. It is estimated that 30,000 babies are born each year as a result of TDJ.l Although there have been many reports concerning the medical aspects of TD I, 2-4 little is known about its psychological effects. There are psychological issues throughout the entire process, including the couple's initial decision to proceed with TDI, the evaluation, the insemination itself, and parenting if treatment is successful. Psychological issues include the effect of the length of time between diagnosis of male infertility and the couple's beginning TDI, the role of psychological counseling during

Received February 25, 1991; revised and accepted May 23, 1991. *Department of Obstetrics and Gynecology, Division of Endocrinology and Infertility. t Department of Psychiatry. :j: Reprint requests and present address: Susan C. Klock, Ph.D., Department of Psychiatry, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115. Vol. 56, No.3, September 1991

the process, the couple's concerns about the TDI child, their preferences about the gender and profession of the person performing the insemination, the effect of the husband's presence at the insemination, the frequency of sexual intercourse after insemination,_ the couple's decision about whether to keep TDI confidential, and marital adjustment after TDI. To investigate these aspects of TDI, we surveyed couples who had conceived through TDI. These couples have been through the entire process, from the decision to proceed with TDI, the inseminations themselves, through conception. This provided a uniform sample to survey who had time to deal with these issues. MATERIALS AND METHODS

Seventy-nine married couples conceived via TDI at the University of Connecticut Health Center from 1982 to 1989. Current addresses were available for Klock and Maier Donor insemination

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70 couples. The couples were sent a preparatory letter describing the study, informing them that they would be receiving a questionnaire in the mail, informing them that their responses would be anonymous and confidential, and requesting their participation. Two weeks after the initial letter, the study questionnaires described below were sent.* Separate questionnaires were provided for the husband and wife. The questionnaires were returned to the investigators in a stamped, self-addressed envelope. Thirty-four couples returned the questionnaire in addition to one woman and one man from separate couples yielding a response rate of 50% (70 individuals). These two individuals were not included in the couples' analyses. The study was approved by the University of Connecticut Institutional Review Board. Two couples completed the questionnaire but strongly objected to being contacted about the TDI. Several other couples commented that they felt that sending the questionnaires through the mail was a threat to their confidentiality. Because of these responses, no additional efforts were made to contact nonresponders. The questionnaire packet included the following: (1) a general demographic questionnaire, 9 multiple choice items to describe the sample in terms of age, ethnicity, income, education, occupation, religious affiliation, and religiousity; (2) TDI questionnaire, a 14-item, multiple choice questionnaire designed for this study to assess the reason for TDI, time from diagnosis of male infertility to initiation of TDI, number of cycles to conception, preferences concerning the profession and sex of the person performing the inseminations, and psychological counseling related to the procedure; (3) confidentiality and social network questionnaire, 13 items, both multiple choice and open-ended items, designed for this study to determine if the couple told others about TDI, if they plan to tell the child, if they would tell others if they had to do it over again, a list of people they told, and the reasons they told; and (4) Dyadic Adjustment Scale,5 a-32 item questionnaire that is commonly used to assess marital adjustment. It measures the psychological constructs of consensus, affection, cohesion, arid satisfaction in the relationship. An overall marital adjustment score is obtained by summing these four scores. Overall scores under 100 are considered indicative of poor marital adjustment.6 * The questionnaire is available from the first author upon request. 490

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Descriptive statistics were used because of the qualitative nature of the data. Frequency counts, means, SDs, and correlation coefficients were used to summarize the data. Chi-square analyses were used to detect differences between groups with a level of P < 0.05 of significance. Paired t-tests were used to analyze couples' data with a level of P < 0.05 of significance. An F max statistic7 was used to determine the ratio of variance for some items. Not all respondents answered all questions; therefore, the number of respondents included in an analysis are indicated when it is less than the total sample. RESULTS Demographics

A summary of the demographics is given in Table 1. Data on wife's age, duration of marriage, and eth-

nicity were available for nonresponders. The nonresponders were significantly older than the responders (nonresponders 35.2 years, SD 3.8, P < 0.01) but did not differ in terms of duration of marriage and ethnicity. Length of Time Between Diagnosis and Beginning TDI

Twenty-nine percent of the couples waited <1 month between the time of diagnosis and the initiation of TDI. Twenty-seven percent waited 1 to 6 months, 18% waited 7 to 12 months, 6% waited 13 to 24 months, and 20% waited >2 years before beginning TDI. Concerns Before Having a TDI Child

The means and SDs of the couples' concerns about having a TDJ child are given in Table 2. Because of the large variances observed in these data, an F max statistic was calculated to determine the ratio of variance. This test was significant; therefore, the data were graphed and inspected for systematic biases. The graphs indicated large floor and ceiling effects for seven of the nine items (>40% of the respondents endorsing the lowest or highest response category). A ceiling effect was observed with the genetic and medical concern item. Floor effects were seen in all the items related to acceptance of the child, and the wife betrayal and husband letdown items. The items regarding personality and physical resemblance had no floor or ceiling effects. For these two items, paired t-tests indicated significant differences between men and women (P < 0.001). Fertility and Sterility

Table 1

Demographic Composition of the Sample Data

Age of total sample (y) Men Women Duration of marriage (y) Ethnic background(%) Caucasian Hispanic Other Occupation(%) Professional Full-time parent Skilled labor Managerial Other Education(%) High school Some college College grad Grad hours/MA M.D./Ph.D./J.D. Yearly income(%) $10,000 to 29,999 $30,000 to 49,999 $50,000 to 69,999 $70,000 to 89,999 $90,000+ Religious affiliation Catholic Protestant Jewish Agnostic/atheist Other

34.8 37.4 32.3 8.2

± ± ± ±

5.7 (25 to 56)" 6.6 (28 to 56) 3.3 (25 to 38) 3.5 94.3 2.8 2.8 42.8 22.8 17.1 11.4 5.6 12.8 17.1 35.7 31.3 2.8 4.4 26.5 44.1 20.5 4.4 44.3 32.8 10.0 7.1 5.7

Average yearly religious service attendance: 14.3 visits± 18.1 (0 to 60, mode O)" No. of children(%) None One Two Three Four Reason for TDI (%) Oligospermia/ azoospermia Previous vasectomy Genetic problems No fertilization at IVF Other

6 50 31 10 52.8 24.3 8.6 2.8 8.6

• Values are means ± SD with range in parentheses.

Eighty-eight percent reported no counseling after the procedure. When asked their opinion about a mandatory pre-TDI psychological consult, 39% (13 of 33 couples) felt that couples should have such a consult, 30% felt they should not, and 30% of the couples disagreed with each other about such a consult. Of those 10 couples who disagreed with one another, in 9 the husband felt the pre-TDI psychological consult should not be mandatory. When asked whether counseling should at least be available to couples during the process, 82% of couples felt that it should be, 0% said it should not, and 18% couples had a split decision. Preferences About the Gender and Profession of the Person Performing the Insemination

When asked their preference about the gender of the person performing the insemination, the majority (69%) of the sample reported no preference. Of those with a preference, all 31% preferred a female inseminator (X 2 P < 0.0002). Seventy-two percent of the sample reported no preference regarding whether the inseminator was a doctor or nurse. Of those subjects with a preference, significantly more men preferred a doctor, whereas women preferred a nurse (X 2 P < 0.006). Husband's Presence at the Insemination

The husband was present for the TDI in 62% of the couples. Sixty-six percent of the wives whose husbands were present reported that it was helpful, 5% said it was detrimental, and 29% reported that it had no effect. Of the husbands who were present, 85% said it helped their wives, 0% said it made it worse, and 15% said it had no effect. Sexual Intercourse After Insemination

Forty-one percent (14 of 33 couples) reported that they had intercourse after inseminations, 35% (12 of 33 couples) did not. Eight of 33 couples (23%) disagreed about whether they did or not. Confidentiality About TDI

Women were more concerned with physical resemblance and men were more concerned with personality resemblance. Provision of Psychological Counseling Before and After TDI

Ninety-one percent of the couples reported that they had no psychological counseling before the TDI. Vol. 56, No.3, September 1991

Forty percent of the 70 individuals (17 men, 11 women) told no one about the TDI, and 60% (18 men, 24 women) told at least 1 person. Of those 42 subjects who told someone, 43% (8 men, 10 women) told 1 or 2 people, 36% (7 men, 8 women) told 3 to 7 people, and the remaining 21% (4 men, 5 women) told between 8 and 14 people. In descending order of frequency, the most common people to be told of Klock and Maier

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Table 2

Concerns About the TDI Child" Item

Physical resemblance Personality resemblance Genetic/medical concerns Acceptance by spouse Acceptance by self Acceptance by family Acceptance by friends Wife betraying husband by having a TDI child Husband having "let down" wife by being infertile

Male 4.51 3.91 5.63 2.14 2.40 1.76 1.35

± ± ± ± ± ± ±

Female

2.09 2.05 2.00 1.75 2.10 1.68 1.15

5.03 3.46 5.46 3.51 1.46 1.19 1.42

± ± ± ± ± ± ±

1.87 1.65 1.44 2.11 0.86 0.40 1.03

Total sample (n = 70) 4.77 ± 3.68 ± 5.54 ± 2.83 ± 1.93 ± 1.48 ± 1.38 ±

1.98 1.86 1.73 2.04 1.66 1.26 1.08

1.39 ± 1.15

1.80 ± 1.39

1.60 ± 1.31

2.85 ± 2.30

3.40 ± 2.12

3.13 ± 2.21

Values are means± SD. • The item format: "I was concerned about the . . ."with a response of 1 indicating "not at all" concerned to 7 indicating "very much" concerned.

TDI are: mother, father, best friend, referring physician, close friend, sister, brother, therapist, coworker, and employer. When asked why they told others, the reasons most commonly cited by the subjects, in descending order, were: to share confidential information, to help celebrate the pregnancy, to help the subject make up their mind about doing TDI, to talk about the psychological issues related to TDI, to help prepare for childbirth, to help with childcare, and to give financial support. Interestingly, when asked, "If you had to do it over again, would you tell anyone else about the TDI," 87% of the total sample (n = 59, 32 men, 27 women) reported that they would tell no one. Of the 42 who had told someone, 81% (n = 34, 16 men, 18 women) said they would not tell anyone if they had to do it over again. There was a negative correlation between the number of people told and the subject's decision to tell others if they could do it over again (r = -0.61). Plans to Tell the Child About His/Her TDI Origin

When asked if they plan to tell the child, 86.5% (58 of 70 subjects) reported that they have not told nor do not plan to tell the child. The most common reason given for not telling is that it would complicate the child's life for no necessary reason. Another common response emphasized that the husband is the father and therefore disclosure about the sperm donor is unnecessary and could be detrimental to the father/child relationship. The third type of response was that the couple had intercourse after the insemination and therefore the husband could be the biological father. Of those subjects who told the child, they reported that they did because the child 492

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"had a right to know," and/or they would not want the child to find out from someone other than the parents. There was a negative correlation between the number of people told and the individual's plan to tell the child of its TDI origin (r = -0.35). Marital Adjustment

The mean, SDs, and range for the total scores and the four subscales of the Dyadic Adjustment Scale are given in Table 3. Thirteen percent of the sample had total dyadic adjustment scores below the cutoff of 100 indicating below average adjustment. There was no correlation between time to initiation of TDI and total marital adjustment (r = 0.08). No relationship (r < 0.20) was found between total marital adjustment scores and several other variables such as age, duration of marriage, number of children, husband present for the insemination, number of people told about TDI, telling others if they had to do it over again, telling the child of its TDI origin, gender of inseminator, profession of inseminator,

Table 3

Dyadic Adjustment Score Scale

Total dyadic adjustment (maximum 151) Consensus subscale (maximum 65) Satisfaction subscale (maximum 50) Cohesion subscale (maximum 24) Affect subscale (maximum 12)

Score 115.34 ± 14.67 (77 to 147)" 49.96 ± 5.89 (37 to 64) 40.21 ± 5.33 (23 to 48) 16.21 ± 3.76 (9 to 23) 8.99 ± 2.02 (4 to 12)

• Values are means ± SD with ranges in parentheses.

Fertility and Sterility

sex after insemination, pre-TDI counseling, or postTDI counseling. DISCUSSION

The current study gathered information about several psychological variables related to TDI. Previous research has focused on the medical aspects of TDI or the opinions of health care providers; there has been minimal examination of the attitudes, beliefs, and preferences of those who have actually undergone the procedure. Although the present study had a relatively high (50%) return rate for studies of this type, 8 the results must be interpreted with caution because it is unclear how the responders differ from the nonresponders. The time taken between diagnosis of male infertility and initiation of TDI was highly variable. Berger9 had previously observed that there was more marital discord when couples began TDI shortly after male infertility was diagnosed. Contrary to that observation, there was no such relationship found in our study. There are several concerns that these couples have about a child conceived through TDI. Clayton and Kovacs 10 reported that most patients seem to be concerned about the medical and/or the genetic background of the donor. Clinically, couples frequently express their concerns about a medical condition present in the donor that may be discovered during the course of the child's life. Some couples also express their concern that the child will not look like or act like the husband. The results of the current study document that genetic/medical factors, physical resemblance, and personality resemblance are prominent concerns. The marked ceiling effect for the genetic and medical concern item illustrates the magnitude of this concern. The range of responses was more evenly distributed for the physical and personality resemblance items. Women were more concerned with the physical resemblance, whereas men were more concerned with the personality resemblance of the child. The remaining items had marked floor effects, suggesting that these concerns are not particularly troubling to most of the subjects in the study. Further information is needed, using other psychometric assessment techniques to determine if this pattern of response is typical of other TDI couples. Opinions have differed regarding the need for a psychological consultation before TDI. Several researchers favor a psychological consultation, 10- 14 whereas others are opposed. 1•15 Although the majorVol. 56, No.3, September 1991

ity of the subjects in the current study did not have a psychological consultation before TDI, they believed that counseling should be available. Moreover, over a third of the couples thought it should be mandatory. Resistance to a mandatory psychological consultation seems to be stronger among men, although it is unclear whether this is because of their hesistancy to discuss the male factor infertility that necessitated the TDI or if this reflects a general trend for men to be more hesitant than women to seek out psychological support. The majority of subjects had no preference about the gender or profession of the person performing the insemination. The minority of subjects with a gender preference all preferred a female inseminator. This finding may be understood from at least two perspectives. One, from psychoanalytic writers, 14•16 states that TDI has a component of adultery when the wife becomes pregnant with another man's sperm. From this perspective both men and women may prefer a female doing the insemination to decrease the connotations of another man and adultery. Alternatively, a more parsimonous explanation may be that patients feel more comfortable with female personnel because females are, in general, perceived as more nurturing and empathicY The majority of subjects had no preference for a physician versus a nurse performing the insemination; however, in the small group who did have a preference, men preferred a physician and women preferred a nurse. The minority of men with a preference may prefer a physician to make the procedure seem more medical and less sexual. Alternatively, they may perceive physicians as more competent and therefore would want them to do the procedure to increase the likelihood of success. The minority of women who had a preference preferred a nurse. Again, this may be because of the perceived nurturing and empathy attributed to females. These interpretations are confounded by the gender of the professional since many of our physicians are women. The husband was present for the procedure in over half the sample. His presence was perceived as helpful by both partners. Rubin 16 observed that many couples have the husband present to increase his involvement in the procedure. Clamar18 reported that physicians recommend that the husband be present for the procedure. This recommendation seems to be supported in this sample. Forty-one percent of the couples had sexual intercourse after the insemination. The couples may have done this to increase the likelihood that the husband would be (or be perceived as) the biological Klock and Maier Donor insemination

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as well as psychosocial father. Their ability to later deny the TDI origin of the child can be maximized if they know they had intercourse after the insemination. It is unclear if this type of denial would be beneficial or detrimental to the child's and family's functioning. Interestingly, the chance that the husband is the biological father, through postinsemination intercourse, is a reason reported by the couples for not telling the child about the TDI. Issues of confidentiality are very important to couples undergoing TDI. Therapeutic donor insemination is different from adoption because of the unequal biological contribution (oocyte and gestation) by the mother, the strict confidentiality of recordkeeping, societal disapproval for TDI, and the lack of physical resemblance with the parents that may exist with adopted children. Some have recommended telling the TDI child and others to remove the secrecy surrounding TDI. 19-21 Unfortunately, the effect of telling or not telling on the child's or the family's adjustment is not known. An initial step in understanding this problem is to ask TDI couples about what they did. The information from the couples in this study was striking because of the 42 subjects who told someone, 81% said that if they had to do it over again, they would not tell anyone. This appears to indicate that many individuals felt, in retrospect, that telling others was either unnecessary or detrimental. Telling others about the TDI may affect whether the couples decide to tell the child or not. If a couple has told many other people, they may feel forced to tell the child for fear that the child may find out from someone else. Although the majority of the people in this study had told at least one other person, the majority have not or do not intend to tell the child. This may underlie their regret about telling others, e.g., if a couple told several people before the child's birth, now that the child is growing up the parents may be concerned that one of the people who knows about the TDI may tell the child. Therefore, if the couple had to do it over again, they would not tell anyone because then they would not feel compelled to tell the child. Clinically, patients discuss their ambivalent feelings of having to tell the child because others already know versus not telling the child because the husband is the psychosocial father. The importance of confidentiality is illustrated by patients' response to this study. Two couples who participated had a strong negative reaction about being in the study. They completed the study materials but requested never to be contacted again by 494

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the clinic. Also, several couples felt that sending materials about TDI through the mail was a threat to their confidentiality. Many authors have noted that a stable marriage is a prerequisite for TDI, 10- 12 although few have assessed marital adjustment after the procedure. Amuzu et al. 2 found that when couples were asked "Did artificial insemination affect your marriage either for the better or worse?" more than half (54%) thought it had improved their marriage, and only 3% thought it had a detrimental effect. Our sample, up to 7 years after successful TDI treatment, reports average marital adjustment. The results from the current study elaborate on Amuzu's by providing a more thorough measure of marital adjustment. These results are also consistent with O'Hara et al., 22 who found an overall marital adjustment score of 111 in a sample of childbearing couples at 9 weeks postdelivery. Marital adjustment in couples in which TDI does not result in a pregnancy may differ. The results of this study raise several issues from both the clinical and research perspectives. First, in this sample there was no clear relationship between time from diagnosis to TDI and subsequent marital adjustment. Further prospective research is needed to clarify the effect of waiting on marital adjustment. On the basis of this study, it does not seem necessary to counsel couples to wait several months after a diagnosis of male factor infertility has been made before pursuing TDI. Second, couples are primarily concerned with the potential genetic/medical background and with physical and personality resemblance to the father of the TDI child. It would be interesting to see if couples given this information about the donor before the procedure have fewer concerns about it or if these concerns change over time. For example, the couple might have initial concerns about the medical aspects but lose those concerns once they realize the child is healthy. Third, it appears that psychological counseling should be available, if not mandatory for this group of patients. Our clinic has recently made a psychological consultation before beginning TDI a routine part of clinical care. The purpose of this interview is to provide the patients with an opportunity to discuss their reactions to the infertility, confidentiality issues, and their expectations about treatment success. Last, the result that was most striking was that people seemed to regret telling others about the TDI. Therefore, a rigid position that "honesty is the best policy" for these couples may not be appropriate. Fertility and Sterility

During the couples' discussion with their physician and with the psychologist, they can discuss a plan that is most comfortable for them which will hopefully lead to the best outcome for themselves and the child.

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10. Clayton C, Kovacs G: AID: a pretreatment social assessment. Aust N Z J Obstet Gynaecol 20:208, 1980 11. Adamson D: Clinical management of psychological issues in therapeutic donor insemination. (Abst.) Presented at the 22nd Annual Postgraduate Course of The American Fertility Society, San Francisco, California, October 1989. Published by The American Fertility Society, in the Program Supplement, 1989, p 53 12. Stewart C, Daniels K, Boulnois J: The development of a psychosocial approach to artificial insemination of donor sperm. Aust N Z Med J 95:853, 1982 13. David A, Avidan D: Artificial insemination donor: clinical and psychological aspects. Fertil Steril 27:528, 1976 14. Gerstel G: A psychoanalytic view of artificial donor insemination. Am J Psychother 17:64, 1963 15. Waltzer H: Psychological and legal aspects of artificial insemination (AID): an overview. Am J Psychother 36:91, 1982 16. Rubin B: Psychological aspects of human artificial insemination. Arch Gen Psychiatry 13:121, 1965 17. Williams J: Psychology of Women, 2nd edition. New York, W.W. Norton & Co., 1983, p 154 18. Clamar A: Psychological implications of donor insemination. Am J Psychoanalysis 40:173, 1980 19. Manuel C, Chevret M, Czyba J: Handling of secrecy by AID couples. In Human Artificial Insemination and Semen Preservation, Edited by G David, W Price. New York, Plenum Press, 1980, p 419 20. Matot J, Gustin M: Filiation and secrecy in artificial insemination with donor. Human Reprod 5:632, 1990 21. Rowland R: The social and psychological consequences of secrecy in artificial insemination by donor (AID) programmes. Soc Sci Med 21:391, 1985 22. O'Hara M, Zekowski E, Phillips L, Wright E: Controlled prospective study of postpartum mood disorders: comparison of childbearing and nonchildbearing women. J Abnorm Psycho! 99:3, 1990

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