Psychological aspects of donor insemination: evaluation and follow-up of recipient couples

Factors associated with discontinuation in fertility treatment: a systematic scoping review

PURPOSE

The discontinuation of fertility treatment could decrease the chances of achieving parenthood for infertile patients and often leads to economic loss and medical resource waste. However, the evidence on the factors associated with discontinuation is unclear and inconsistent in the context of fertility treatment. This scoping review aimed to summarize the evidence on factors associated with discontinuation in fertility treatment, identify the current knowledge gap, and generate recommendations for future research.

METHODS

We searched PubMed, Embase, The Cochrane Library, Web of Science, CINAHL, American Psychological Association, and http://clinicaltrials.gov from inception to June 2023 without language or time restrictions. We also searched the grey literature in Open Grey and Google Scholar and hand-searched the reference lists of relevant studies to identify potentially eligible studies. Publications that studied factors associated with discontinuation in fertility treatment were included. The identified factors were mapped to the World Health Organization's treatment adherence model.

RESULTS

Thirty-seven articles involving 41,973 infertile patients from 13 countries were included in this scoping review. All studies identified the factors from the perspective of patients, except for one that described the factors from the healthcare providers' perspective. A total of 42 factors were identified, with most of them belonging to the patient-related dimension, followed by socio-economic-related, treatment-related, condition-related, and healthcare system-related dimensions. Female education level, social support, and insurance coverage decreased the likelihood of treatment discontinuation, whereas multiparous women, male infertility, depression, higher infertility duration, and treatment duration increased the likelihood of treatment discontinuation. Age, education level, and ethnicity are the commonly nonmodifiable factors for treatment discontinuation, while insurance coverage, depression, and anxiety symptoms are among some of the more commonly reported modifiable factors.

CONCLUSION

This is the first scoping review examining and synthesizing evidence on the factors influencing of discontinuation in fertility treatment. This review could inform researchers, clinicians, and policymakers to address modifiable barriers and facilitators to develop personalized and multicomponent interventions that could improve the discontinuation in fertility treatment.

The Attitudes of Infertile Male Patients Toward the Use of Artificial Insemination by Donor: A Korean Regional Survey

Purpose

Infertile couples interested in nonspouse artificial insemination by donor (AID) not only require a thorough understanding of the medical procedure but also must scrutinize the effects it will have on family relationships, including those on the infant to be born. We conducted a series of surveys in couples with male infertility to collect information necessary for AID counseling.

Materials and Methods

A total of 384 cases with noncurable male infertility were enrolled in this inquiry survey. The questionnaire consisted of 18 items that assessed demographic characteristics, background information concerning the choice to use AID, subjective experiences, long-term effects, and an overall evaluation.

Results

A total of 126 surveys were returned (32.8%). AID was first suggested by the husband in about half of the cases. The major reason for considering the procedure was to form a complete family. Two-thirds of the couples were anxious about the procedure, most often about possible congenital or acquired deformities in the infant. After the birth of the child, most couples were positive about their decision to have used AID. About half of the couples felt that the child was their own and expected not to tell the child about AID. Overall, about 50% of the couples were satisfied with the procedure.

Conclusions

Those who underwent AID experienced various psychological effects, including anxiety about the child to be born. To overcome these problems, sufficient medical information and consultation about the process of selecting the donor and about AID procedures should be provided before the procedure is used.

Why do patients discontinue fertility treatment? A systematic review of reasons and predictors of discontinuation in fertility treatment

BACKGROUND Chances of achieving parenthood are high for couples who undergo fertility treatment. However, many choose to discontinue before conceiving. A systematic review was conducted to investigate patients' stated reasons for and predictors of discontinuation at five fertility treatment stages. METHODS Six databases were systematically searched. Search-terms referred to fertility treatment and discontinuation. Studies reporting on patients' stated reasons for or predictors of treatment discontinuation were included. A list of all reasons for discontinuation presented in each study was made, different categories of reasons were defined and the percentage of selections of each category was calculated. For each predictor, it was noted how many studies investigated it and how many found a positive and/or negative association with discontinuation. RESULTS The review included 22 studies that sampled 21 453 patients from eight countries. The most selected reasons for discontinuation were: postponement of treatment (39.18%, postponement of treatment or unknown 19.17%), physical and psychological burden (19.07%, psychological burden 14%, physical burden 6.32%), relational and personal problems (16.67%, personal reasons 9.27%, relational problems 8.83%), treatment rejection (13.23%) and organizational (11.68%) and clinic (7.71%) problems. Some reasons were common across stages (e.g. psychological burden). Others were stage-specific (e.g. treatment rejection during workup). None of the predictors reported were consistently associated with discontinuation. CONCLUSIONS Much longitudinal and theory led research is required to explain discontinuation. Meanwhile, treatment burden should be addressed by better care organization and support for patients. Patients should be well informed, have the opportunity to discuss values and worries about treatment and receive advice to decide about continuing treatment.

Why do patients discontinue fertility treatment? A systematic review of reasons and predictors of discontinuation in fertility treatment

BACKGROUND

Chances of achieving parenthood are high for couples who undergo fertility treatment. However, many choose to discontinue before conceiving. A systematic review was conducted to investigate patients' stated reasons for and predictors of discontinuation at five fertility treatment stages.

METHODS

Six databases were systematically searched. Search-terms referred to fertility treatment and discontinuation. Studies reporting on patients' stated reasons for or predictors of treatment discontinuation were included. A list of all reasons for discontinuation presented in each study was made, different categories of reasons were defined and the percentage of selections of each category was calculated. For each predictor, it was noted how many studies investigated it and how many found a positive and/or negative association with discontinuation.

RESULTS

The review included 22 studies that sampled 21 453 patients from eight countries. The most selected reasons for discontinuation were: postponement of treatment (39.18%, postponement of treatment or unknown 19.17%), physical and psychological burden (19.07%, psychological burden 14%, physical burden 6.32%), relational and personal problems (16.67%, personal reasons 9.27%, relational problems 8.83%), treatment rejection (13.23%) and organizational (11.68%) and clinic (7.71%) problems. Some reasons were common across stages (e.g. psychological burden). Others were stage-specific (e.g. treatment rejection during workup). None of the predictors reported were consistently associated with discontinuation.

CONCLUSIONS

Much longitudinal and theory led research is required to explain discontinuation. Meanwhile, treatment burden should be addressed by better care organization and support for patients. Patients should be well informed, have the opportunity to discuss values and worries about treatment and receive advice to decide about continuing treatment.

Tackling burden in ART: an integrated approach for medical staff

Discontinuation is a problem in fertility clinics. Many couples discontinue assisted reproductive technologies (ART) without achieving a live birth for reasons other than poor prognosis or the cost of treatment. Discontinuation has been attributed to the burden of treatment. The causes of burden can be broadly classified according to whether they originate in the patient, clinic or treatment. Interventions to alleviate these burdens include provision of comprehensive educational material, screening to identify highly distressed patients, provision of tailored coping tools and improvements in the clinic environment and medical interventions. Practical interventions to reduce the different causes of burden in ART exist, but further development and evaluation of the efficacy of these interventions requires more precise definition of terms and theory. In this paper, we propose a general integrated approach to cover different perspectives in dealing with burden in ART clinics. We firstly describe the integrated approach and present common sources of burden. We then describe interventions that could help reduce the burden in ART. Our paper is aimed at fertility clinic staff because of their day-to-day involvement with patients. However, this discussion should also be relevant to companies that develop treatments and to psychosocial experts. Reducing the burden of treatment should lead to improved outcomes, namely better quality of life during treatment and lower discontinuation rates.

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

OBJECTIVE

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

DESIGN

In-depth ethnographic interviews.

SETTING

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

PATIENT(S)

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

INTERVENTION(S)

Husbands and wives were interviewed together and separately.

MAIN OUTCOME MEASURE(S)

Thematic analysis of interview transcripts.

RESULT(S)

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

CONCLUSION(S)

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

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

OBJECTIVE

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

DESIGN

Qualitative, naturalistic design, using a phenomenological approach.

SETTING

The home or private office of the recipient woman.

PATIENT(S)

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

RESULT(S)

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

CONCLUSION(S)

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

Donor gametes and embryos: who wants to know what about whom, and why?

Many treatments for infertility require the use of donated gametes or embryos. Arguments have been made that all parties involved (donors, recipients, and children) should have open access to information about one another. The present article reports a survey of attitudes of 77 donors and 327 recipients in the state of Western Australia. Donors and recipients endorsed a register of nonidentifying information, but were less keen on a register of identifying information. They believed that medical personnel should have access to such registers, and that donors and recipients (but not children) should have access to nonidentifying, but not identifying, information. Typically, the sort of information respondents wanted to access pertained to health status and physical characteristics. Overwhelmingly, both donors and recipients saw gamete and embryo donation as more like blood donation than like adoption.

School-aged children of donor insemination: a study of parents' disclosure patterns

BACKGROUND

A major concern in relation to donor insemination (DI) is whether children should be told about their genetic origins. This study compared the thoughts, feelings and experiences of DI parents who were inclined towards openness with those who were inclined towards non-disclosure.

METHODS

Forty-six families with a 4- to 8-year-old DI-conceived child were interviewed about their decision, their reasons and subsequent concerns regarding disclosure.

RESULTS

Thirty-nine percent of parents were inclined towards disclosure whilst the remaining 61% were not. The two main reasons for favouring disclosure were to avoid accidental discovery and a desire for openness. Non-disclosing parents felt that there was no reason to tell and wished to protect family members. The children who had been told reacted with either curiosity or disinterest.

CONCLUSIONS

In spite of donor anonymity, parents who were intending to tell their child in the future had optimistic expectations of their child's reaction. Parents who had already told their child generally described the telling experience as a positive one.

Semen providers and their three families

BACKGROUND

In 1985 the Swedish government introduced legislation that required all semen providers to furnish identifying information on themselves which would then be made available to their biological/provider offspring when they are deemed to have 'sufficient maturity'. The purpose of the legislation was to protect the child's rights and needs. The aim of this paper is to examine the degree to which semen providers have considered the implications of their decision to donate upon their three families; their birth family, the family they form with their partner, and the recipient family.

METHODS

Thirty semen providers from two Swedish clinics were sent self-completion questionnaires collecting both quantitative and qualitative information. The initial response rate was 100%. Questions requested demographic information; the degree to which semen providers had consulted with or advised their partners, family, existing offspring and acquaintances about their semen donation; views and attitudes of semen providers towards donor offspring, anonymity, information sharing, payments to semen providers, community acceptance of DI and semen providers, experience of donation, recruitment/screening procedures.

RESULTS

Almost all respondents had told their partners that they were providing semen, however, a much smaller proportion had told their birth families. Almost two thirds of semen providers were positive or very positive about the prospect of meeting their offspring at some time in the future, with older men expressing more enthusiasm.

CONCLUSIONS

The findings suggest that semen providers have only partially considered and addressed the full implications of having semen provider offspring. The age of semen providers could be influential in determining some attitudes and views.

L'impact de l'infertilité et de ses traitements sur la vie sexuelle et la relation de couple : revue de la littérature

This paper reviews the literature on the psychosocial impact of infertility and its treatments by the ART on the marital sexuality, by paying special attention to the relationship between gender and the infertility experience. It is convenient to divide this literature into articles that explore the sexual life of the infertile couples on the one hand, and those focusing on the couple relationship - marital satisfaction and marital adjustment-, on the other hand. The literature on the infertile couples' sexuality and sexual satisfaction, mostly descriptive, presents infertility as a deleterious experience for both women and men even if the repercussion differ according to gender, with correlative dynamic effects within the couple. The contributions to the investigation of the couple relationship, mostly quantitative Anglo-Saxon studies, have produced equivocal or contradictory results concerning the satisfaction with the relationship, the closeness between the two partners so that it is difficult to assume a trend in this field. This situation is largely due to the problems of sampling. In this view, future research should perform its methodological apparatus to take into account the processual nature of the infertility experience, at both levels of couple history and its involvement in the ART process.

Psychogenic infertility--myths and facts

PURPOSE

The hypothesis of this review is that the role of psychological factors as the sole cause of infertility is generally overrated.

METHODS

A review is given of studies concerning the influence of psychological factors on the development of infertility.

RESULT

A prevalence of psychogenic infertility of 10-15 per cent must be discussed critically. A value of approximately 5 per cent is more realistic. Equating unexplained infertility with psychogenic infertility is not justified. A definition of psychogenic infertility according to the German guidelines Psychosomatics in Reproductive Medicine is presented. Spontaneous pregnancies following adoption or the decision to remain childless are the absolute exception. The association of stress and infertility in humans is still unclear. For many women the effect of infertility and notably of medical therapy is a considerable emotional stress. This may make psychosocial counseling necessary in certain cases.

CONCLUSIONS

An exclusive psychological/psychodynamical point of view on the complexity of infertility is as inadequate as a strictly somatic point of view. Infertility should always be treated as a psychosomatic entirety.

Practitioner review: outcomes for parents and children following non-traditional conception: what do clinicians need to know?

BACKGROUND

The birth of the first 'test-tube' baby in 1978 has led to the creation of family types that would not otherwise have existed.

METHODS

This paper examines research on the psychological outcomes for parents and children in assisted reproduction families with particular attention to the issues and concerns that have been raised by creating families in this way.

RESULTS

Parents of children conceived by assisted reproduction appear to have good relationships with their children, even in families where one parent lacks a genetic link with the child. With respect to the children themselves, there is no evidence of cognitive impairment in singleton children born at full term as a result of assisted reproduction procedures, although the findings regarding the cognitive development of intracytoplasmic sperm injection (ICSI) children are currently unclear. In relation to socioemotional development, assisted reproduction children appear to be functioning well.

CONCLUSIONS

Few studies have included children at adolescence or beyond, and little is known about the consequences of conception by assisted reproduction from the perspective of the individuals concerned. In addition, there are some types of assisted reproduction family, such as families created through a surrogacy arrangement or through embryo donation, about whom little is known at all. Although existing knowledge about the impact of assisted reproduction for parenting and child development does not give undue cause for concern, there remain a number of unanswered questions in relation to children born in this way.

Recruitment and motivation of semen providers in Sweden

BACKGROUND

Legislation in Sweden requires that semen providers are prepared to be identified to offspring (at maturity) should this be requested. This study presents views of semen providers in Sweden regarding factors associated with their recruitment and motivation.

METHODS

All semen providers (n = 30) in two clinics in different parts of Sweden participated in a questionnaire survey and both quantitative and qualitative data are reported.

RESULTS

While there were some important demographic differences between the two clinic populations, there was total agreement that the desire to assist infertile couples was the sole or main motivating factor in becoming a semen provider. Monetary reward was not reported by respondents to be an important motivator, although at least 50% of the providers in both clinics thought that payment should be made and reimbursement of expenses was reported as being important. Men responded to both advertising and personal experiences or contacts they had with infertile couples. The involvement and support of the semen provider's partner was regarded as important.

CONCLUSIONS

Semen providers can be recruited within a system that requires them to be prepared to be identified to offspring in the future. The characteristics of such providers vary, but are typified by a strong desire to assist infertile couples.

The European study of assisted reproduction families: the transition to adolescence

BACKGROUND

Findings are presented of the second phase of a European longitudinal study of families created by assisted reproduction. The present investigation reports on data obtained during the child's transition to adolescence.

METHODS

A total of 102 IVF families, 94 donor insemination (DI) families, 102 adoptive families, and 102 families with a naturally conceived child were compared on standardized interview and questionnaire measures of parenting and children's psychological well-being.

RESULTS

The assisted reproduction families were similar to the adoptive and natural conception families for many of the measures of the quality of parent-child relationships. To the extent that differences were found between the assisted reproduction families and the other family types, these reflected mainly more positive functioning among the assisted reproduction families, with the possible exception of the overinvolvement with their children of a small proportion of assisted reproduction mothers and fathers. The assisted reproduction children were functioning well and did not differ from the adoptive or naturally conceived children on any of the measures of psychological adjustment. However, only 8.6% had been told about their genetic origins.

CONCLUSIONS

IVF and DI families with an early adolescent child appear to be functioning well.

Disclosure of donor insemination to the child: the impact of Swedish legislation on couples' attitudes

The question whether or not parents of children conceived after donor insemination (DI) tell their offspring about its biological background was addressed. Swedish legislation from 1985 gives the child born after DI the right, when grown up, to receive identifying information about the sperm donor. Until now no information about compliance with the law has been available. All parents who gave birth to a child by DI after the new legislation in two major Swedish fertility centres (Stockholm and Umeâ) received a questionnaire containing questions about the issue of informing the child. The response rate was 80%. The majority of parents (89%) had not informed their children, whereas 59% had told someone else. As a response to an open question, 105/132 parents chose to comment on their answer about not having informed their child. Of these families, 61 intended to tell their child later, 16 were not sure and 28 were not going to inform the child. Compliance with the law must be regarded as low since only 52% of the parents had told or intended to tell their child. In addition, concern is raised about the children who run the risk of being informed by someone other than their parents.

Do attitudes toward disclosure in donor oocyte recipients predict the use of anonymous versus directed donation?

OBJECTIVE

To compare the demographic and psychological characteristics of oocyte recipients and to determine whether the issue of disclosure about the use of a donor is a correlate of the decision to use an anonymous or directed donor.

DESIGN

Cross-sectional study.

SETTING

University teaching hospital.

PATIENT(S)

Ninety consecutive recipients of donated oocytes (64 of whom used anonymous donors and 26 of whom used directed donors).

INTERVENTION(S)

Pretreatment psychosocial evaluation.

MAIN OUTCOME MEASURE(S)

Recipient opinions and attitudes regarding the choice of donor type and disclosure to others as determined through a semistructured interview.

RESULT(S)

There were no statistically significant differences with regard to demographic characteristics between recipients who used anonymous and directed donors. There were statistically significant differences between the groups with regard to the issue of disclosure. Recipients who used directed donors were more likely to have told others about using an oocyte donor and were more likely to indicate that they intended to inform the child about the nature of his or her conception.

CONCLUSION(S)

Oocyte recipients who use known donors differ significantly from those who use anonymous donors with regard to the issue of disclosure to others. Further studies are needed to determine the causal direction of this relation.

The disclosure decision: concerns and issues of parents of children conceived through donor insemination

OBJECTIVE

The purpose of our study was to examine the disclosure decision by parents of children conceived by donor insemination.

STUDY DESIGN

A qualitative component of a self-administered questionnaire mailed to 184 couples who had become parents by donor insemination encouraged respondents to volunteer their written comments, concerns, or opinions about their disclosure decision.

RESULTS

A total of 70 men and 86 women submitted written comments indicating that 54% did not plan to disclose the donor insemination treatment (nondisclosers), 30% indicated they would (disclosers), and 16% remained undecided. The only significant relationship between the disclosure decision and expressed concern was with regard to confidentiality and honesty (chi2 = 99.9, p < 0.05).

CONCLUSIONS

Whether parents viewed the disclosure issue as one of honesty (disclosers) or confidentiality (nondisclosers) was the major determinant in the decision of whether to tell children about their donor insemination origin. There was no association between disclosure status or gender and expressed concerns about parenting, children, or family relations.

Infertility and psychological distress: a critical review of the literature

This essay reviews the literature on the social psychological impact of infertility, paying special attention to the relationship between gender and the infertility experience. It is convenient to divide the literature into articles which explore the possibility that infertility may have psychological causes (Psychogenic Hypothesis) and those which examine the psychological consequences of infertility (Psychological Consequences Hypothesis). The psychogenic hypothesis is now rejected by most researchers, but a related hypothesis, which states that stress may be a causal factor in infertility, is worthy of exploration. The descriptive literature on the psychological consequences of infertility presents infertility as a devastating experience, especially for women. Attempts to test the psychological consequences hypothesis have produced more equivocal results. In general, studies which look for psychopathology have not found significant differences between the infertile and others. Studies which employ measures of stress and self-esteem have found significant differences. The psychological consequences literature is characterized by a number of flaws, including over sampling of women, small sample size, non-representative samples, failure to study those who have not sought treatment, primitive statistical techniques, and an over-reliance on self-reports. Studies on infertility and psychological distress need to take into consideration both the duration of infertility and the duration of treatment. Finding an appropriate set of "controls" is a particularly intractable problem for this area of research. In general, the psychological distress literature shows little regard for the social construction of infertility. By taking what should be understood as a characteristic of a social situation and transforming it into an individual trait, the literature presents what is essentially a medical model of the psycho-social impact of infertility. Most researchers conclude that infertility is a more stressful experience for women than it is for men. Most studies have found that the relationship between gender and infertility distress is not affected by which partner has the reproductive impairment. Future research needs to be better informed by theoretical considerations. Scholars need to pay more attention to the way the experience of infertility is conditioned by social structural realities. New ways need to be developed for better taking into account the processual nature of the infertility experience. Efforts need to be make to include under-studied portions of the infertile population. Finally, more effort needs to be made to better integrate the empirical study of the experience of infertility with important social policy questions.

Disclosure issues and decisions of couples who conceived via donor insemination

Disclosing the use of donor insemination (DI) to family, friends, and offspring poses a quandary for many DI patients. A cross-sectional survey was conducted to determine whether couples opted to share information about conception via donor sperm with their children, as well as the issues and concerns that arose for parents once infertility treatment was completed. Twenty-seven married heterosexual infertile husbands and wives who had used DI to conceive completed a follow-up questionnaire asking them about disclosure decisions as well as thoughts about DI as a reproductive option. Results revealed that nearly three-quarters of the sample had not disclosed to their child and did not plan to, although 85% had told at least one other person about conception via DI. With few exceptions, husbands and wives agreed about how to handle disclosure. Notably, 32% of the mothers reported not knowing when or how to disclose. However, the majority of couples were not offered psychological counseling prior or subsequent to DI. It is suggested that mental health professionals should be aware of the divergence of opinion between what they believe about the benefits of disclosure/counseling, the beliefs of infertile couples about disclosure and what is actually known about the benefits of full disclosure among all involved parties.

Donor insemination: attitudes of parents towards disclosure

OBJECTIVE

To determine attitudes of parents of children conceived by donor insemination to telling the children of their origin.

DESIGN

Questionnaire survey, in 1992-1993, of parents who had had a child by donor insemination at four New South Wales clinics from 1979 to 1990.

SETTING

Three hospital-based clinics (two public, one private) and a private clinic service.

PARTICIPANTS

276 families who altogether had had 420 children by donor insemination.

MAIN OUTCOME MEASURES

Number of children told that they had been conceived by donor insemination; parents' intentions, before conceiving and after the birth, of informing the child; and whether other people were informed of the child's origin.

RESULTS

Of 393 families who could be contacted, 353 agreed to participate and 276 (70%) replied to the questionnaire. Only 22 of the 420 children (5.2%) had been informed of their origin. Before conceiving, 18% of parents (49/273) planned to tell the child. Seventy-one per cent of families (182/257) had told others of the origin of the child, but 94% (241/257) had not told the child. Of the 29% of families (75/257) who had not told others of the child's origins, none had told the child. As the children grow older, more parents decide not to tell them of their origin.

CONCLUSIONS

Most parents of children conceived by donor insemination do not plan to tell their child, but most of these parents have told others, creating the potential for accidental disclosure. Because of the small number of children who are told of their origin, there may not be a need for government-regulated donor registers, provided donor insemination units maintain a high standard of record-keeping.

Stigma, disclosure, and family functioning among parents of children conceived through donor insemination

OBJECTIVE

To examine the influence of gender, male infertility factor, and other demographic variables on stigma and whether parents tell their children that they were conceived by donor insemination (DI) and to ascertain if stigma and the disclosure decision affect parental bonding with the child or the quality of the interparental relationship.

DESIGN

One hundred eighty-four San Francisco Bay Area couples who had become parents by DI were asked to complete a self-administered questionnaire.

SETTING

A private infertility practice.

PATIENT(S)

Eighty-two men and 94 women who completed the questionnaire.

MAIN OUTCOME MEASURE

A questionnaire assessing disclosure, stigma, parental bonding, and the quality of the interparental relationship.

RESULT(S)

Factors that increased the couple's likelihood of disclosure included younger age, azoospermia, lower stigma scores, and having more than one DI child. Fathers who scored higher on stigma reported less parental warmth and parental fostering of independence.

CONCLUSION(S)

Because the decision regarding disclosure of DI treatment was not linked to parental bonding with the child or to the quality of the interparental relationship, we cannot conclude that nondisclosure is harmful to family relationships or is a symptom of family problems. The husband's perceptions of stigma however, may affect the father--child relationship adversely.

Feelings of couples who have had a child by donor insemination: the degree of congruence

The study aimed to assess the congruence of feelings about donor insemination (DI) in couples who have had a child by this means. Male and female partners of 50 couples (in continuing relationships) who had had a child by DI individually completed a questionnaire. A Likert scale (0, very unhappy to 7, very happy) was used to assess feelings before, during and after treatment, and the perception of their partner's feelings. Individual partner's responses were also compared for views about the donor and assessment of their relationship. For both males and females, their feelings about DI before, during and after treatment did not correlate with their perceived view of their partner's feelings. This difference was much more striking before treatment started with male feelings (mean +/- SD) being 4.1 +/- 1.8 compared to the females' perception of the males' feelings of 3.5 +/- 1.9 (t test, p = 0.004) and females' feelings of 3.7 +/- 2.0 compared to the males' perception of female feelings of 4.3 +/- 2.0 (p = 0.05). In comparing attitudes about the donor, individual couples' views did not correlate well, the exceptions being their views on whether or not to have another child and whether they wanted the same donor. All but one couple agreed that the DI child had brought them closer together as well as agreeing that they confided in each other. The marital interaction assessment showed close compatibility in most issues. The impact of DI on couples affected by male factor infertility raises many issues, the views of which may not be shared between partners. This is especially the case of attitudes about the donor and is of some concern when viewed in the wider context of marital and parent-child relationships. It is not known whether these opposing views have an impact on the later development of these relationships but they should be considered as part of the preparation for beginning treatment.

Successful donor insemination and its impact on recipients

Male and female partners of couples who conceived a child by donor insemination (DI) independently completed a questionnaire. Fifty-seven women and 53 men representing 58 couples taking part. Fifty-one were in a continuing relationship and seven were separated. A likert scale (0-7) of "happiness' before, during and after treatment and their perception of their partner's feelings were used as measures. These feelings were evaluated in relation to demographic and clinical factors. Fifty-one women and 49 men who were in a continuing relationship answered questions about their feelings about DI, compared to six and three, respectively, who had separated. Feelings about DI were consistently low before treatment began. For both continuing and separated couples there was an improvement of their feelings about having DI during treatment, and then again after treatment was complete. For the male partner, factors that were associated with greater unhappiness included difficulties with the relationship prior to treatment, waiting time for treatment and subsequent separation. The women, however, had more positive experiences with no measured factors adversely affecting their feelings about DI. The arrival of the DI child had a significant effect in improving the relation-ship. Our findings suggest that for many couples acceptance of the DI program was less than ideal and only improved with having the treatment and then conceiving. The data highlight the need for psychosocial assistance to be made available to couples prior to the commencement of treatment.

Donor insemination: a comparison of lesbian couples, heterosexual couples and single women

OBJECTIVE

To compare single women, lesbian couples, and heterosexual couples receiving therapeutic donor insemination (TDI).

DESIGN

Chart review followed by anonymous mail questionnaires to donor insemination recipients and their partners.

SETTING

Infertility clinic in a university hospital.

PATIENTS

One hundred fifteen women receiving donor insemination were identified by chart review.

RESULTS

Too few single women responded for reliable comparison. Lesbian women were similar to married women in age, education, duration, and outcome of donor insemination. When considering alternatives to TDI, married women were more likely to consider adoption and lesbians were most likely to consider using a known semen donor or having intercourse with a man aware of their desire to have a child. Married couples were less likely to tell others, including the child, about conception by donor insemination. They were also less likely to support disclosing identifying data about the donor to the child. Lesbians were more likely to report stress in their relationships as a result of TDI. Married men were most likely to support mandatory counseling before TDI initiation.

Donor insemination, the impact on family and child development

The practice of donor insemination (DI) has undergone major changes in the past 20 years. Attention was paid to the long-term psychological effects, the pleas for openness became stronger over the years and the use of anonymous donors became subject to public debate in several countries. The present article reviews what empirical research there is into DI families and their children. Over the years follow up studies have appeared sporadically and in spite of the varying quality of the research methods, preliminary findings have emerged. Research into the confidentiality issue in DI couples revealed that 47-92% of the DI parents intended to keep the donor origin secret from their children. DI couples just starting treatment more often intended to tell their children the DI origin than those who already had children. It is, however, too early to tell whether the public pleas for more openness did affect attitudes of the DI patients themselves. Research into the psychological well-being of DI parents and children failed to reveal major psychological problems. DI parents appeared to be well adjusted and to have stable marital relationships. DI children did not show significantly more emotional disturbances than controls. The quality of the parent-child relationship was better in the DI group than in the controls of naturally conceived parents.

Telling donor insemination offspring about their conception: the nature of couples' decision-making

The issue of openness and secrecy in the use of donor gametes is the subject of considerable disagreement and debate, not only for social scientists and health professionals, but also for the recipients of donor gametes. This paper has its origins in a study of 58 couples who had a child/children as a result of donor insemination (DI) at the Dunedin Infertility Clinic. Respondents completed questionnaires and took part in an interview during which they were asked whether they intended to tell their offspring about their DI conception. The nature of agreement/disagreement between partners on this issue, the dynamics operating between couples that may affect decision-making, and the views of couples in a time-frame perspective are the focus of this paper. Transcripts from some of the interviews are presented to illustrate the points made and commentary and discussion is provided.

Factors related to preferences in gamete donor sources

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.

A prospective study of donor insemination recipients: secrecy, privacy, and disclosure

OBJECTIVES

To study prospectively the attitudes and behaviors of heterosexual couples undergoing donor insemination.

DESIGN

Couples undergoing donor insemination completed psychological questionnaires before treatment regarding psychiatric symptoms, self-esteem, marital adjustment, and their attitudes about privacy or disclosure.

PARTICIPANTS

Forty-one of 82 heterosexual couples participated.

MEASURES

A donor insemination questionnaire, a self-esteem scale, the Brief Symptom Inventory, and the Dyadic Adjustment scale were used.

RESULTS

Psychiatric symptoms, self-esteem, and marital adjustment were all in the normal range. The amount of time taken by the couple to decide to do donor insemination was not related to reported psychiatric symptoms, self-esteem, marital adjustment, or marital satisfaction. Ninety-five percent of the couples believed a psychological consultation should be a mandatory part of the donor insemination treatment. The greatest concern the couples had about the donor child was its genetic and medical background. Thirty-eight percent of the couples did tell or planned to tell others about using donor insemination to conceive, and only 27% of the couples planned to tell the child of his or her donor origin.

CONCLUSIONS

The results of this study support those of others, which have indicated that the majority of donor recipients are psychologically well adjusted and have average marital adjustment. In addition, this prospective study replicated the findings of other retrospective studies, indicating that most donor insemination recipients do not plan to tell the child of his or her donor origin. Additional prospective studies are needed to determine if attitudes and behavior regarding disclosure change over time.

Secrecy: an unresolved issue in the practice of donor insemination

There is a paucity of information on the well-being of the families created through artificial insemination with donor sperm despite its widespread availability for more than a generation. Physicians who practice donor insemination have historically supported or encouraged secrecy while observing that couples are satisfied and well adjusted after the birth of their donor insemination offspring. However, from the perspective of the child's best interests, it has been argued that accurate genealogic knowledge should be a "right" and that an ethical conflict exists if the practitioner and the couple act together to deceive the child about his or her true genetic identity. The recognition that secrecy raises difficult social, psychologic, and ethical questions while holding considerable practical and emotional appeal for the couple is a major unresolved issue in the practice of donor insemination. It is suggested that further study and evaluation of donor insemination families is needed if accurate counseling and advice are to be provided to couples considering the option of donor insemination.

Withdrawal from a donor insemination programme

The aim of this study was to examine the factors that influenced the withdrawal of couples from a regional donor insemination programme. Demographic, medical, treatment and outcome data were prospectively recorded on 375 referrals. One hundred and eight women had conceived at least 1 normal pregnancy. Withdrawals from the programme, without pregnancy, accounted for 165 couples, whilst 47 had begun treatment, and a further 29 were on the waiting list. Thirty nine (24%) of those withdrawing did so without notice or reason. Most of these (33) were in couples waiting to begin treatment. Natural conception, adoption, identifiable medical or social reasons (including separation) and moving to another region were the predominant causes for withdrawing. Women who had entered the programme because of their partner's oligospermia had a high natural conception rate. Age, socioeconomic status, geographic location and length of infertility did not affect the withdrawal rate.