Would ‘all-inclusive’ compensation attract more gamete donors to balance their loss of anonymity?

Differences between sperm sharing and egg sharing are morally relevant

Sperm sharing arrangements involve a man ('the sharer') allowing his sperm to be used by people seeking donor sperm ('the recipients') in exchange for reduced price in vitro fertilisation. Clinics in the UK have offered egg sharing since the 1990s and the arrangement has been subjected to regulatory oversight and significant ethical analysis. By contrast, until now no published ethical or empirical research has analysed sperm sharing. Moreover the Human Fertilisation and Embryology Authority (HFEA) does not record the number of sperm sharing arrangements taking place.This paper describes the sperm sharing process providing an analysis of all the UK clinics advertising sperm sharing services. The ethical rationale for egg sharing is described: reducing the number of women exposed to the risks of stimulation and retrieval. This advantage is absent in sperm sharing where donation has no physical drawbacks. The key adverse social and emotional outcome of gamete sharing arises when the sharer's own treatment is unsuccessful and the recipient's is successful. This outcome is more likely in sperm sharing than in egg sharing given sperm from sharers can be used by up to 10 families whereas shared eggs only go to one other family.Given its morally relevant differences from egg sharing, sperm sharing requires its own ethical analysis. The HFEA should begin recording sperm sharing arrangements in order to enable meaningful ethical and policy scrutiny.

Support for recognition and payment options for egg and sperm donation in New Zealand and Australia

STUDY QUESTION

To what extent do infertility clinic patients, fertility industry professionals and members of the public support different forms of payment and recognition for egg and sperm donation?

SUMMARY ANSWER

While participants expressed support for reimbursement of expenses for both egg and sperm donation, payment constituting explicit financial advantage was regarded less favourably although potentially necessary to address donor gamete shortages.

WHAT IS KNOWN ALREADY

In both New Zealand and Australia, commercial inducement for the supply of gametes is prohibited. This prohibition has been argued to contribute to limited availability of donor gametes with the effect of increasing waiting lists and/or the pursuit of potentially unregulated cross-border reproductive care by domestic patients requiring donor gametes.

STUDY DESIGN, SIZE, DURATION

The study was a mixed methods study drawing on data from a questionnaire completed by 434 participants from across New Zealand and Australia between November 2018 and March 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Stakeholders involved in donor-assisted conception (past and present infertility patients, gamete recipients and donors), fertility industry professionals and members of the public were recruited following online advertisement of the study. All participants spoke English and primarily identified as Caucasian. Participants anonymously completed an online questionnaire gauging their support for a range of recognition and payment options. Dependent samples t-tests were used to probe for differences in support of recognition and payment options in relation to egg and sperm donation. Linear regression models were used to determine factors predicting support for the different options for both egg and sperm donation. Thematic analysis was used to identify main themes in free text question responses.

MAIN RESULTS AND THE ROLE OF CHANCE

Broadly, there was agreement that donors be reimbursed for medical expenses, travel time, unpaid time away from work relating to treatments and out-of-pocket expenses directly related to the gamete donation process, with greater support suggested for egg versus sperm donors. Items gauging support for non-material recognition and tokens of thanks for donations were not significantly different between egg and sperm donation programmes (P > 0.05) nor rated as highly as reimbursement alternatives. Lowest ratings of support were indicated for the outright payment or reward of donors for the supply of their gametes, options that would leave donors in better financial positions. Qualitatively, themes valuing gamete donation as ideally relating to gifting were identified, although counterbalanced in opinion by concepts of fairness in reimbursing gamete donors for their costs. Where payment over and above the reimbursement of costs was supported, this was related to pragmatic considerations of limited supply of donor gametes.

LIMITATIONS, REASONS FOR CAUTION

This study used a cross-sectional design and consequently causal inferences cannot be made. Additionally, participants particularly professional fertility staff, were required to self-report on politically sensitive and legal issues with the potential for social desirability response bias. Snowball sampling may have led to participation of like-minded individuals, thus limiting generalizations of findings.

WIDER IMPLICATIONS OF THE FINDINGS

In a climate of global commercialization of reproductive medicine, limited donor gamete availability and rising incidences of cross-border reproductive care, the findings of this study can be used as a basis for further discussion between regulators and professional industry stakeholders with respect to shaping ethical policy and practice relating to donor conception.

STUDY FUNDING/COMPETING INTEREST(S)

No external funds were sought for this work. None of the authors have any competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Open-Identity Sperm Donation: How Does Offering Donor-Identifying Information Relate to Donor-Conceived Offspring's Wishes and Needs?

Over the past years, a growing number of countries have legislated open-identity donation, in which donor-conceived offspring are given access to the donor's identity once the child has reached maturity. It is held that donor anonymity creates identity problems for such children similar to the "genealogical bewilderment" described within the adoption context. The study of the social and psychological effects of open-identity donation is still very much in its infancy, but what has been left unquestioned is whether (and to what extent) offering access to the donor's name and address is an adequate response to such effects. This study has two goals: First, we aim to provide a systematic review of the reasons why donor-conceived (DC) offspring want to know the identity of their sperm donor. Second, we examine to what extent the provision of donor-identifying information can satisfy the reasons mentioned. The most important motivations appear to be: (1) to avoid medical risks and consanguineous relationships; (2) to satisfy curiosity; (3) to learn more about the self or to complete one's identity; (4) to learn more about what kind of person the donor is (biographical information, why he donated, etc.); (5) to form a relationship with the donor and/or his family; and (6) to learn about one's ancestry/genealogy. Our analysis shows that for nearly all of these reasons access to the donor's identity is not necessary. In those cases where it is, moreover, donor identification is not sufficient. What is really needed is (extended) contact with the donor, rather than the mere provision of his name.

Recipients' views on payment of sperm donors

The aim of this qualitative study was to explore how recipients viewed payment of sperm donors. The study was conducted in Belgium, where, as in many countries, sperm donors receive recompense for their time and expenses. Face-to-face semi-structured interviews were conducted with 34 heterosexual and lesbian couples who, at the time of data collection, had at least one donor-conceived child aged 7-10 years or who were undergoing donor conception treatment. Although participants commonly described the issue of financial compensation as something that did not really concern them, all supported the idea that some level of payment was acceptable or even necessary. The participants also identified several ways in which donor payment offered advantages to their own position as (future) parents. Although the idea is commonly rehearsed that sperm donation is a gift and that monetary transaction for conception is demeaning, the participants of this study did not generally share this view. To them, a small financial return served as a symbolic acknowledgement of the donor's contribution and helped secure the type of relationship they expected from their donor. There was clearly concern, however, over high payments and the risk of attracting the wrong kind of donor.

Payment of egg donors in stem cell research in the USA

Arguments have been put forth as to whether women who donate oocytes for human embryonic stem cell (HESC) research should be compensated, but data regarding this issue have been scant. Recently in the United States, several States have begun funding HESC research, and patient recruitment efforts have begun. This paper lays out relevant arguments and presents data concerning this issue. Researchers are finding that women are unwilling to donate eggs altruistically, which is hampering the progress of research. These efforts are examined, and data on potential donors' views are presented. The absence of payment, rather than ethical concerns, appears to explain opposition to donation. Women also appear generally ignorant of policies in this area. It is suggested that policy discussions shift focus from whether to pay, to how much would be appropriate, and how to decide; and that research and public and professional education be increased to heighten understanding and awareness of these issues.

Mirror gametes donation

Candidate recipients of donor gametes have a moral obligation to make a contribution to the system from which they benefit by reciprocating. They can do this as a couple when the partner of the person who has no usable gametes donates and receives the mirror gametes in return. In an indirect exchange system, the couple receives bonus points for their donation so that their waiting time for the gametes is reduced or even fully canceled. A system of strict reciprocity is rejected as unfair because it excludes categories of people from access to donor gametes. Also candidate recipients who for medical or psychological reasons do not qualify as donors should have access to donor gametes on the basis of points collected on other criteria. Not only contribution but also need (the wish to have a child) should be taken into account when allocating donor gametes. The mirror exchange system can alleviate the shortage of both sperm and egg donation in an ethically acceptable way.

UK gamete donors' reflections on the removal of anonymity: implications for recruitment

BACKGROUND

In 2005, UK legislation was changed requiring any donor of gametes or embryos used in the treatment of others to agree to the disclosure of their identity to any offspring reaching the age of 18.

METHODS AND RESULTS

This paper analyses responses of a survey of existing donors' views on the removal of donor anonymity that was undertaken by the Department of Health (UK) as part of its review that preceded changes to the law on donor anonymity. The survey provides an insight into what it is about the loss of anonymity that some donors find problematic, indicating that although some donors will be reluctant to donate under conditions of non-anonymity, others have concerns about the removal of anonymity that can be addressed.

CONCLUSIONS

This paper identifies factors, in particular counselling, support and better information that could maintain gamete donor recruitment in the context of the UK's policy of non-anonymous and non-remunerated donation.

Donor gametes: anonymous or identified?

The practice of gamete donation has, until recently, been shrouded in secrecy. The stigma associated with infertility and, in particular, donor insemination has been the main factor contributing to this secrecy. Over the last 20 years, this secrecy and the anonymity of the gamete donors has been challenged. In the first instance, the challenge came from governments in some countries legislating to abolish donor anonymity. Counsellors, social workers and psychologists advocating for the interests and needs of children and their families, as well as parents who did not wish to keep gamete donation secret from their children, were also instrumental in the change of policies and practice. Those offspring who know that they were conceived as a result of gamete donation are also calling for an end to the secrecy. This chapter reviews the changes that have occurred and which are still occurring, and reviews the research associated with these changes.

Alternative solutions to the current situation of oocyte donation in Singapore

The rising incidence of age-related female infertility in Singapore, coupled with the prohibition on commercialized oocyte donation and egg sharing, has resulted in a severe shortage of donor oocytes. Infertile women are routinely encouraged by fertility doctors here to seek their close relatives and friends as prospective oocyte donors, which does not alleviate the shortage. A number of alternative solutions are discussed. The use of substantial financial remuneration to encourage oocyte donation is rejected as being legally, ethically and morally incompatible with present day Singaporean society. Egg sharing in return for subsidized fertility may have a strong case for ethical justification, but implementation would need amendment of the current legislation in Singapore. Cross- and mirror-exchange oocyte donations face less of a legal challenge in Singapore and also have a strong case for ethical justification. However, special consideration must be given to the unique socio-cultural values of Singaporean society, i.e. traditional Chinese culture. Finally, if no changes are made to restrictive regulations governing oocyte donation in Singapore, and shortage of donor oocytes still persists, then reproductive tourism abroad may be the solution for some patients; referrals by local fertility doctors are unlikely to be allowed in Singapore.

Gamete donation in a system of need-adjusted reciprocity

A new paradigm to collect and allocate donor gametes is proposed. In the system, called indirect mirror exchange, the partner of the person who needs donor gametes, donates in exchange for bonus points that are awarded to the infertile person. All candidate recipients of donor gametes are ranked on a waiting list and receive points according to waiting time, medical urgency, phenotypic resemblance and contribution. According to the principle of fairness, persons who benefit from a system are obliged to contribute their share. However, strict reciprocity is rejected as unfair. A contribution by the couple is thus not a necessary condition for access to the waiting list. The system of reciprocity is adjusted by taking account of need considerations. The number of bonus points awarded to contributors should be high enough to move them to the front section of the waiting list.

Commentary on Craft and Thornhill: new ethical strategies to recruit gamete donors

The main problem for the procedure of gamete donation at present is that the abolition of the donor anonymity rule has destroyed coherence among the guidelines. To restore coherence, a new unified picture of the role of the gamete donor should be constructed. It is doubtful that payment will increase the number of candidates in a system with identifiable donors. Nevertheless, if non-financial rewards of donors do not suffice to motivate candidates, an 'all-inclusive' financial allowance analogous to volunteers in medical trials could be considered to prevent a complete collapse of the system.

Ethical issues in paying for long-distance travel and accommodation expenses of oocyte donors

In many countries where the sale and purchase of donor oocytes is banned, a legal loophole often exploited is the use of free air tickets and hotel stay to entice prospective oocyte donors, in lieu of monetary payment. Such a means of procuring much-needed donor oocytes is ethically unsound. There is a lack of transparency and the personal motivation of the oocyte donor may be clouded by the desire for a 'free' holiday. Moreover, such a system is open to abuse by medical professionals. Private fertility clinics may source for oocyte donors to attract patients. The oocyte donor is paid nothing (except free travel and hotel stay), while the medical professional makes a handsome profit from treating infertile patients, which is not equitable. Medical professionals can also easily make a profit by marking up the price of air tickets and hotel stay to the patient (oocyte recipient). This would be thoroughly unprofessional, since the money earned is not directly related to the medical skills and expertise of the fertility specialist. Hence, it is imperative that various regulatory authorities should critically re-examine the giving of free travel and accommodation to oocyte donors, instead of monetary compensation.