Will removal of anonymity influence the recruitment of egg donors? A survey of past donors and recipients

Shifting to a model of donor conception that entails a communication agreement among the parents, donor, and offspring

Background

Some persons conceived with donor gametes react negatively when they found their birth via donor conception. They request access to information about and seek to communicate with the donor. However, some countries mandate donor anonymity. Other countries allow donor-conceived persons to access donor information, but they can only use this access if their parents have disclosed donor conception to them. We investigated a thorny issue of donor conception: whether donor conception should be shifted from an anonymous basis to a non-anonymous basis.

Methods

We review the issues and concerns regarding donor conception. We then consider the impact of direct-to-consumer genetic testing on donor conception, as well as the influence of donor conception on offspring’s identity and the potential of different types of donors. To discuss the future policy of donor conception, the policies on the anonymity of gamete donors were investigated using publicly-available documents in 15 countries.

Results

The aim of mandating donor anonymity is to protect the privacy of the donor and intended parents. However, the diffusion of direct-to-consumer genetic testing may make it impossible to maintain anonymity. Birth via donor conception shapes the offspring’s identity, and the donor may further influence the development of offspring’s identity through communications. It remains important to disclose donor conception to donor-conceived offspring and to provide them with donor information. However, that information might be insufficient for some donor-conceived persons. Here are benefits to having open-identity donors and known donors. Such donors can make an agreement with the parents regarding future communication with the offspring, although both sides should respect privacy. Subsequent counseling for all parties involved can result in better tripartite communication agreements.

Conclusions

In sum, ethical and practical issues that complicate donor anonymity are driving a shift to non-anonymous donor conception, in which all parties come to a communication agreement. To pave the way for such a donor conception system, transitional measures can be put into place. For countries that already adopted non-anonymous donor conception, ensuring the communication agreements is important to protect the rights of parents, donor, and offspring.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00756-1.

Views of French oocyte donors at least 3 years after donation

RESEARCH QUESTION

The study aimed to evaluate the percentage of oocyte donors who regretted their donation at least 3 years later.

DESIGN

Between December 2018 and January 2019, this single-centre study sought to contact by telephone all women who had donated oocytes during the 6-year period from 2010 to 2015 at the Lille Centre for the study and storage of eggs and spermatozoa (CECOS).

RESULTS

Among 118 women, 72 responded to the questionnaire by telephone and were included in the study. The response rate was 61%. No woman regretted having donated an oocyte, and 89% said that they would do it again in the same situation. The survey distinguished two types of donors: 'relational' (58%) and 'altruistic' (42%); some of their responses differed. Ninety per cent of the women had talked about the donation to family and friends. Among them, 74% felt supported by their family and friends, and 72% by their partner. The donation was something that 76% of the women sometimes thought about; 83% felt that this donation was something useful that they had accomplished. Finally, most donors felt that oocyte donation should remain unremunerated and anonymous.

CONCLUSIONS

None of the donors we interviewed regretted their donation. In France, the current principles governing this donation appear satisfactory to oocyte donors.

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.

Egg donors' motivations, experiences, and opinions: A survey of egg donors in South Africa

The objective of this study was to gain information from egg donors in South Africa (SA) which could be pertinent to policy development on egg donation. The study was conducted on egg donors in the database of a Cape Town-based egg donation agency who donated within a year preceding the study. 150 egg donors from the population of 226 participated in an online survey. The main results are: 95% of respondents experienced egg donation as being positive. However, 7% of respondents report not giving proper informed consent, and a similar percentage of respondents also report not knowing whether any medical risks actually materialised as sequelae to their donations. This is a cause for concern and should be investigated further. Regarding donor anonymity, which is currently the legal position in SA, 79% of respondents indicated that they would still have donated had they been legally required to release their identities. Accordingly, possible legal reform away from the current system of donor anonymity seems unlikely to significantly impact the supply of donated eggs. Regarding motivation, respondents report being primarily motivated by wanting to help infertile women. However, respondents believe that a fair and realistic amount of compensation would be about 60% higher than what is currently paid as the national standard fixed amount. This fixed-amount compensation system should be further investigated in terms of its legality, impact on donor profile, and its current amount.

"I want us to be a normal family": Toward an understanding of the functions of anonymity among U.S. oocyte donors and recipients

BACKGROUND

Anonymity remains the more common practice in gamete donations, but legislation prohibiting anonymity with a goal of protecting donor-conceived children's right to know their genetic origins is becoming more common. However, given the dearth of research investigating the function of anonymity for donors and recipients, it is unclear whether these policies will accomplish their goals. The aim of this study was to explore experiences with anonymity among oocyte donors and recipients who participated in an anonymous donor oocyte program and to understand the ways in which anonymity functions for them.

METHODS

Semistructured interviews were conducted with 50 women: 28 oocyte donors and 22 recipients who were recruited from an academic center for reproductive medicine in the United States.

RESULTS

Donors and recipients view anonymity both as a mechanism to protect the interests of all parties (recipients, donors, and donor-conceived children) and as a point of conflict. Specifically, three key areas were identified where both donors and recipients saw anonymity as having an important role: relieving anxieties about family structures and obligations; protecting their interests and those of donor-conceived children (while acknowledging where interests conflict); and managing the future.

CONCLUSION

As gamete donation increasingly moves away from the practice of anonymity, examining why anonymity matters to stakeholders will be helpful in devising strategies to successfully implement identity-release options.

A systematic review investigating psychosocial aspects of egg sharing in the United Kingdom and their potential effects on egg donation numbers

This review aims to provide an up-to-date knowledge of the psychosocial aspects of egg donation from the perspectives of the egg share donor and their recipient. It explores the motives, experiences and attitudes of egg sharers and their views towards donor anonymity and disclosure. Conclusions are made on how these findings can guide clinical practice and improve egg sharing numbers. A systematic search of peer-reviewed journals of four computerized databases was undertaken. Eleven studies were included in the review. Psychosocial aspects towards donation were positive from the egg share donor and recipient. Concerns raised were whether participating in the egg sharing scheme would impact on their success rates, as well as frustration expressed by a minority regarding the lack of knowledge of egg sharing outside of fertility clinics. The 2005 legislative changes in the UK have not caused the anticipated dramatic decrease in egg donation; however, oocyte donation still falls short of demand. Egg sharing provides a practical option for more patients to access IVF, whilst also providing more donor oocytes. Improved information provision will result in greater awareness of egg sharing, with the potential to recruit more donors and meet the needs of recipients currently on long waiting lists.

Altruism or obligation? The motivations and experience of women who donate oocytes to known recipients in assisted conception treatment: an interpretative phenomenological analysis study

INTRODUCTION

This qualitative study was conducted to explore the motivations and experience of oocyte donors donating to women known to them.

METHODS

Three women who donated oocytes to a close relative were interviewed and data were analysed using an Interpretative Phenomenological Analysis approach.

RESULTS

The two key elements noted were "motivations for donation" and "coping with the consequences of oocyte donation". The motivation for donation was influenced by the familial bond that was strengthened by the donation process in some cases. The concept of altruistic oocyte donation stemmed from the narratives of giving the gift of motherhood and gaining a positive self-image and respect from others. Coping with the consequences of oocyte donation tests the donor identity, their wishes for a positive outcome, concerns regarding disclosure of biological motherhood and detachment from the egg and potential child.

DISCUSSION

Motivation is influenced by a combination of factors including the rewards of altruistic behaviour, the existence and potential strengthening of the relationship between donor and recipient, but possibly also, a sense of obligation and societal expectations. Oocyte donation can be variously viewed by donors as a unique way of reproductive empowerment or an example of acceding to subtle coercion and thus disempowerment. The study also highlights the clinical as well as ethical importance of providing support services for oocyte donors and recipients.

[Are patients in the postpartum period potential egg donors?]

OBJECTIVES

In France, oocyte donation program is still underdeveloped because of lack of donors and this situation entails an important wave of cross border medical tourism to different European countries mainly Spain and Greece. In 2011, the General inspection of social affairs report recommended to the biomedicine agency to promote spontaneous oocyte donation via different channels of information to develop this national program. The main objective of this study is to assess the knowledge of women after baby delivery about oocyte donation. The second objective is the identification of ways to assure better information and to promote oocyte donation.

PATIENTS AND METHODS

We conducted a prospective study with anonymous questionnaire distribution to women after delivery at obstetrics/gynecology department of the Regional University Hospital and Maternity-Children Unit "Victor-Pauchet" of Amiens, from December 2012 to January 2013.

RESULTS

Two hundred and fifty-five questionnaires were distributed and 242 of them were analyzed (94.9%). About oocyte donation knowledge: 28% did not know it was possible, 45% did not know it was legal in France, 54% did not know who was concerned and 36% know that a treatment is necessary, 9% think that oocyte donation is paid and 10% it is non-anonymous. If 67% seems to be favorable to this initiative, only 35% could accept to realize it. About information efficiency, 88% think not to receive enough information, 64% would like to have more information. The health care professional wanted to give this information is an obstetrician (51%), a midwife (37%) and a nurse (12%).

DISCUSSION AND CONCLUSION

Oocyte donation program is misoriented due to a lack of information. Obstetricians and midwives have an important educational and informative role to support oocyte donation. Specific strategy of communication and valuable targeted information are needed to motivate potential donor and achieve the objectives of the program.

The oversight and practice of oocyte donation in the United States, United Kingdom and Canada

In vitro fertilization using donated oocytes is an important medical technique that provides the only option for some infertile patients to have children. The technique remains ethically contentious, however, and, as a result of this controversy, different oversight approaches have been developed in countries around the world. This paper examines the oversight and practice of oocyte donation in Canada, the United Kingdom and the United States to examine how policy choices have influenced the development and use of this medical technology. Examining per capita utilization of oocyte donation in these three countries provides evidence that supply-side policies-specifically policies affecting the compensation of potential oocyte donors-have substantially influenced the use of this technology. These results should provide useful insight for policymakers developing or revising oocyte donation policies.

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.

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

The UK Government has determined that children born from egg donation have the same right to know their biological parent as adopted children on reaching the age of 18. There is concern as to the effect of loss of anonymity on egg donor recruitment, since a wait of 1 or 2 years is not unusual even under present circumstances. Some fertility programmes have introduced egg-sharing (involving 'subfertile donors') to circumvent the delays. However, with this method both the donor and the recipient may have reduced overall success. The shortage of sperm donors has led the Human Fertilisation and Embryology Authority (HFEA) to consider increasing the allowable expenses payment and a consultation exercise is underway to review payments and other issues for sperm, egg and embryo donors. Fundamental new initiatives regarding gamete donation need to be implemented to avoid further restrictions on an already unsatisfactory service. An 'all-inclusive' financial allowance is proposed for donors to promote donor recruitment and shorten the waiting time to treatment predicted to increase with the loss of anonymity.

International egg-sharing to provide donor oocytes for clinical assisted reproduction and derivation of nuclear transfer stem cells

Recent advances in nuclear transfer technology for derivation of patient-specific stem cells have opened up new avenues of therapy for various human diseases. However, a major bottleneck is the severe shortage of human donor oocytes. Egg-sharing in return for subsidized fertility treatment has been suggested as an ethically justifiable and practical solution to ease the shortage of donor oocytes both for derivation of nuclear transfer stem cells and assisted reproduction. However, it is envisioned that many patients would be more comfortable with their supernumerary oocytes going into derivation of nuclear transfer stem cells, rather than having another potential anonymous offspring in assisted reproduction. Nevertheless in more economically developed countries, fertility treatment is easily affordable to a large segment of the population, which reduces the pool of available egg-sharers. In less affluent countries, fertility treatment is often beyond the financial resources of most sub-fertile couples. Hence, a possible solution may be to allow egg-sharing across international borders. Potential egg-sharers would come from less economically-developed countries that are more in need of financial subsidies for sub-fertile couples seeking clinically assisted conception. This is ethically justifiable because it makes fertility treatment affordable to childless couples from poorer countries, while at the same time easing the shortage of donor oocytes in more affluent countries.

How would revealing the identity of gamete donors affect current practice?

The possibility of revealing the identity of gamete donors may change the decision of a donor to collaborate with infertility clinics and patients. Previous experiences with patients and donors, as well as different cultural viewpoints in northern and southern Europe, are presented.

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.