Psychological adjustment in adolescents conceived by assisted reproduction techniques: a systematic review

Medically assisted reproduction and mental health in adolescence: evidence from the UK Millennium Cohort Study

BACKGROUND

The number and proportion of children conceived through medically assisted reproduction (MAR) is steadily increasing yet the evidence on their mental health in adolescence is inconclusive. Two main mechanisms with opposite effects can explain differences in mental health outcomes by conception mode: while more advantaged parental characteristics could positively influence it, higher parental stress could have a negative influence.

METHODS

Linear and logistic estimations on a longitudinal population-based birth cohort study of 9,897 individuals to investigate whether adolescents conceived through MAR are more likely than naturally conceived (NC) children to experience mental health problems at age 17, as reported by adolescents themselves and their parents. We test whether this association is confounded and/or mediated by parental background characteristics collected when the cohort member was around 9 months old (maternal age, maternal education level, ethnicity, income quintile), family structure variables measured in adolescence (number of siblings in the household at age 15, parental household structure at age 14) or maternal distress at age 14.

RESULTS

Children conceived naturally and through MAR self-reported similar mental health outcomes. The only differences between MAR and NC adolescents are in the parental reports, with parents who conceived through MAR reporting their children had 3.82 (95% CI: 1.140 to 11.54) and 2.35 (95% CI: 1.145 to 4.838) higher odds of falling within the high category of SDQ total difficulties and emotional symptoms scales, respectively. The results did not change on adjustment for mediators, such as maternal distress, number of siblings in the household and parental household structure.

CONCLUSIONS

The results reveal a lack of or small differences in MAR adolescents' mental health outcomes compared to children who were conceived naturally. While the results based on the parental reports could suggest that MAR adolescents are at higher risk of suffering from mental health problems, the differences are small and not supported by adolescents' own reports. The difference between MAR and NC adolescent's parental report might reflect differences in parental concern, their relationship or closeness and can help to reconcile the mixed findings of previous studies.

Does being conceived by assisted reproductive technology influence adult quality of life?

Numerous studies have investigated the physical health and development of children and adolescents conceived with assisted reproductive technology (ART). Less is known about the quality of life of ART-conceived adults. This study explores the contributions of being conceived with ART and psychosocial cofactors present in young adulthood to the quality of life of adults aged 22-35 years. Young adults conceived through ART or natural conception (NC) completed questionnaires which included a standardized measure of quality of life (World Health Organization Quality of Life - Brief assessment (WHOQoL-BREF)) when aged 18-28 years (T1) and again when aged 22-35 years (T2). The WHOQoL-BREF has four domains: (i) Physical, (ii) Psychological, (iii) Social relationships and (iv) Environment. A total of 193 ART-conceived and 86 NC individuals completed both questionnaires. When accounting for other cofactors in multivariable analyses, being ART-conceived was strongly associated with higher scores (better quality of life) on the Social relationships, and Environment WHOQoL-BREF domains at T2. In addition, less psychological distress, a better relationship with parents, a better financial situation, and perceptions of being about the right weight at T1 were associated with higher scores on one or more of the WHOQoL-BREF domains at T2. In conclusion, being ART-conceived can confer advantages in quality of life in adulthood, independent of psychosocial cofactors.

Psychosocial health and quality of life in ICSI and naturally conceived adolescents: a cross-sectional comparison

PURPOSE

Psychosocial health (PH) and quality of life (QoL) are important health outcomes. We compared PH and QoL of adolescents conceived with intrazytoplasmatic sperm injection (ICSI) and of naturally conceived controls. The impact of disclosure of ICSI-conception on QoL and PH was quantified.

METHODS

The cross-sectional sample consisted of 545 ICSI-conceived adolescents and 427 unmatched singleton controls aged 14-18 years. Adolescents reported PH with the 'Strengths and Difficulties Questionnaire' (low values indicating high PH), and QoL with the KINDL questionnaire (high values indicating high QoL). Because of clustering of multiples within families, adjusted linear regressions with generalized estimating equations were used to compare ICSI- and naturally conceived adolescents. Missing values were treated by multiple imputation. Minimal importance was defined as half a standard deviation.

RESULTS

Both ICSI and control adolescents had high PH (low mean 'total difficulties' score: 9 of 40) and high QoL (mean 'total KINDL' score: 75 of 100). Differences were generally in favour of the ICSI group. Significant differences occurred for 'impact of behavioural problems' (p = 0.033), the 'total KINDL' score (p = 0.021) and the dimensions 'physical wellbeing' (p = 0.031) and 'school' (p = 0.005), but all differences were far below minimal importance. About 80% of ICSI adolescents were informed about their mode of conception. PH and QoL were slightly higher in informed adolescents; behavioural difficulties ('total behavioural problems' and 'conduct problems') were significantly lower (p = 0.013 and p = 0.003), behavioural strengths ('prosocial behaviour') and 'physical QoL' significantly higher (p = 0.004 and p = 0.018), but differences remained clearly below minimal importance.

CONCLUSIONS

Our results are reassuring for parents using ICSI and their children. Speaking openly about an ICSI conception in the family may be beneficial.

Are the children alright? A systematic review of psychological adjustment of children conceived by assisted reproductive technologies

The present systematic review aims to assess the psychological adjustment of children born through assisted reproductive technologies (ARTs) and to screen for clinical problems when compared with normative data from the standardized indexes of mental health. Following PRISMA guidelines, the search was conducted from inception through September 2021 using APA PsycInfo, APA PsycArticles, Psychology and Behavioural Sciences Collection, Academic Search Complete, Pubmed, Scopus, Web of Science, Scielo, and RCAAP. Search terms related to ART and children's psychological adjustment were combined to Boolean operators to identify relevant published studies in English, French, Italian, Portuguese and Spanish. Peer-reviewed studies focused on the psychological adjustment of ART children aged between the 3 and 11 years were included. From a total of 337 results, 45 papers were eligible to be included in this review. Data extraction was performed independently by two authors and revised and confirmed by other two authors. All children scored below the clinical range for psychiatric symptoms when compared with normative data for the Strengths and Difficulties Questionnaire (SDQ) or the Achenbach System of Empirically Based Assessment (ASEBA), regardless of type of ART and different family configurations. Further, some evidence suggests that surrogacy children with gay fathers present the lowest levels of psychological problems when compared to normative data. These findings enable practitioners to develop an informed view of ART children mental health outcomes to help parents find more adaptive strategies to navigate their chosen pathways in healthier ways.

Adolescent Development and the Parent-Adolescent Relationship in Diverse Family Forms Created by Assisted Reproduction

Assisted reproduction techniques (ARTs) are employed by single individuals and couples who are not otherwise able to conceive spontaneously. While the use of ARTs is increasing, research is lacking on the attempts made by adolescent offspring conceived via ARTs to integrate their ART conception into their identity and negotiate a connection with, and autonomy from, their parents. The present article reviews studies investigating adolescent development and the parent-adolescent relationship in diverse family forms created by ARTs (mainly heterosexual and lesbian parent families), and discusses the results in light of attachment, identity development, and emotional distance regulation theories. Overall, the results indicate that the psychological adjustment of adolescents conceived via ARTs is not undermined by the manner of their conception, and that they enjoy positive relationships with their parents with no difference from those enjoyed by spontaneously conceived adolescents. However, it remains unknown whether the development of a reproductive identity in adolescence is likely to influence adolescents' interest in searching for or contacting their donors, surrogates, and/or donor siblings. The results suggest the relevance of considering the parent-adolescent relationship, disclosure, and identity formation issues when planning psychological counseling and support interventions with ART parents and their adolescent offspring, and emphasize the need to further investigate these aspects in diverse ART families, including single-, gay-, bisexual-, and trans*-parent families.

The Well-Being of Adolescents Conceived Through Medically Assisted Reproduction: A Population-Level and Within-Family Analysis

Medically assisted reproduction (MAR) plays an increasingly important role in the realization of fertility intentions in advanced societies, yet the evidence regarding MAR-conceived children's longer-term well-being remains inconclusive. Using register data on all Finnish children born in 1995-2000, we compared a range of social and mental health outcomes among MAR- and naturally conceived adolescents in population-averaged estimates, and within families who have conceived both through MAR and naturally. In baseline models, MAR-conceived adolescents had better school performance and the likelihood of school dropout, not being in education or employment, and early home-leaving were lower than among naturally conceived adolescents. No major differences were found in mental health and high-risk health behaviours. Adjustment for family sociodemographic characteristics attenuated MAR adolescents' advantage in social outcomes, while increasing the risk of mental disorders. The higher probability of mental disorders persisted when comparing MAR adolescents to their naturally conceived siblings. On average, MAR adolescents had similar or better outcomes than naturally conceived adolescents, largely due to their more advantaged family backgrounds, which underscores the importance of integrating a sociodemographic perspective in studies of MAR and its consequences.

Evaluation of the Risk of Birth Defects Related to the Use of Assisted Reproductive Technology: An Updated Systematic Review

Fertility problems constitute a serious medical, social, and demographic problem. With this review, we aim to critically appraise and evaluate the existing literature surrounding the risk of birth defects in offspring conceived using techniques based on assisted reproductive technology (ART). Based on searches of the literature in PubMed and ScienceDirect, we obtained a total of 2,003,275 works related to the topic. Ultimately, 11 original papers published in the last 10 years qualified for inclusion in the study. Based on five studies included in this analysis, it was shown that ART significantly increases the risk of congenital malformations in associated newborns. Due to the specifics of given studies, as well as potential confounding risk factors, this influence cannot be ignored. Therefore, considering the information contained in the articles included in this systematic review, it was determined that the risk of birth defects is not directly related to the use of ART itself but also depends on the age of partners, causes of infertility, comorbidities, and the number of fetuses during a pregnancy, as well as many other factors not covered in the literature. It is thus necessary to impress upon infertile couples who wish to have offspring that the use of ART is not risk-free but that the benefits outweigh the risks. Further education in this field, as well as social understanding, is also required.

Adolescent attachment to parents and peers in singletons and twins born with assisted and natural conception

STUDY QUESTION

Does adolescent attachment to parents and peers differ between singletons and twins born with ART or natural conception (NC)?

SUMMARY ANSWER

Adolescent attachment anxiety with the father was higher among NC singletons than among ART and NC twins, whereas attachment avoidance with the father was higher in ART singletons than in NC singletons and NC twins. No differences were found in attachment to the mother, best friend or romantic partner.

WHAT IS KNOWN ALREADY

Most studies have not found differences between ART and NC singletons in parent–adolescent relationships, but twin relationships may be more at risk. No previous study has examined all four groups in the same study, or specifically looked at attachment relationships.

STUDY DESIGN, SIZE, DURATION

This was an 18-year, prospective and controlled longitudinal study with families of 496 ART singletons, 101 ART twin pairs, 476 NC singletons and 22 NC twin pairs. Families were recruited during the second trimester of pregnancy; the ART group was recruited from five infertility clinics in Finland and the control group was recruited from a hospital outpatient clinic during a routine visit.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers and fathers gave background information for this study during pregnancy, and during the child’s first year and early school age (7–8 years). For the ART group, infertility characteristics and prenatal medical information was also obtained from the patient registry of the infertility clinics. Children (originally 50% girls) filled in electronic questionnaires related to their attachment to mother, father, best friend and romantic partner (Experiences in Close Relationships—Relationship Structures) at 17–19 years of age.

MAIN RESULTS AND THE ROLE OF CHANCE

Adolescent attachment anxiety to father was higher in NC singletons than in ART twins, P = 0.004 and marginally higher than in NC twins, P = 0.06. Adolescent attachment avoidance to father was higher in ART singletons than in NC singletons, P = 0.006 and marginally higher than in NC twins, P = 0.055.

LIMITATIONS, REASONS FOR CAUTION

The sample size was small especially in the NC twin group and there was drop-out over the 18-year time period, especially among boys and families with lower parental education level. The study only included native Finnish-speaking families. The results could differ in a more diverse population. ART singletons were younger and had fewer siblings than ART twins and NC children, and ART and NC twins had more newborn health risks than ART and NC singletons.

WIDER IMPLICATIONS OF THE FINDINGS

The study adds to a growing body of evidence that neither ART treatments nor being a twin places mother–child relationships or peer relationships at long-term risk. However, in our study, which was the first to examine both ART and twinhood simultaneously, we found that there may be more problems in father–adolescent relationships, but only in ART singletons and only related to attachment avoidance. Our findings suggest that men, as well as women, should receive enough support in pre- and peri-natal health care during and after infertility treatments.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Academy of Finland (grant number 2501308988), the Juho Vainio Foundation and the Finnish Cultural Foundation. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

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.

Predicting Academic Alienation From Emotion Dysregulation, Social Competence, and Peer Relationships in School-Attending Girls: A Multiple-Regression Approach

School alienation (SA) refers to a collection of negative attitudes toward the social and academic realms of schooling consisting of cognitive and affective components. The current study was designed to examine whether emotion dysregulation, social competence, and peer problems predict school alienation. In this vein, 300 school-attending adolescents in Sarab were recruited and completed difficulties in emotion regulation scale (DERS), academic alienation questionnaire (AAQ), social competence test (SCT), and index of peer relations (IPR) measures, but 280 (M age = 16.35; SD = 0.82; 46% girls) completed data were gathered. The results of hierarchical multiple regression indicated that school alienation was significantly predicted by emotion dysregulation, social competency, and peer problems. In conclusion, our findings suggest that school psychologists and other clinicians design interventions to improve the students’ shortcomings in emotion regulations, social competency, and peer relationships domains.

OUP accepted manuscript

STUDY QUESTION

What information and support should be offered to donors, intended parents and donor-conceived people, in general and in consideration of the availability of direct-to-consumer genetic testing and matching services?

SUMMARY ANSWER

For donors, intended parents and donor-conceived offspring, recommendations are made that cover information needs and informed consent, psychosocial implications and disclosure.

WHAT IS KNOWN ALREADY

Trends indicate that the use of donor-assisted conception is growing and guidance is needed to help these recipients/intended parents, the donors and offspring, navigate the rapidly changing environment in which donor-assisted conception takes place.

STUDY DESIGN, SIZE, DURATION

A working group (WG) collaborated on writing recommendations based, where available, on evidence collected from a literature search and expert opinion. Draft recommendations were published for stakeholder review and adapted where relevant based on the comments received.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Papers retrieved from PUBMED were included from 1 January 2014 up to 31 August 2020, focusing on studies published since direct-to-consumer genetic testing has become more widespread and accessible. The current paper is limited to reproductive donation performed in medically assisted reproduction (MAR) centres (and gamete banks): donation outside the medical context was not considered.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 32 recommendations were made for information provision and support to donors, 32 for intended parents and 27 for donor-conceived offspring requesting information/support.

LIMITATIONS, REASONS FOR CAUTION

The available evidence in the area of reproductive donation is limited and diverse with regards to the context and types of donation. General conclusions and recommendations are largely based on expert opinion and may need to be adapted in light of future research.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations provide guidance to MAR centres and gamete banks on good practice in information provision and support but should also be considered by regulatory bodies and policymakers at a national and international level to guide regulatory and legislative efforts towards the protection of donors and donor-conceived offspring.

STUDY FUNDING/COMPETING INTEREST(S)

The development of this good practice paper was funded by European Society of Human Reproduction and Embryology (ESHRE), covering expenses associated with the WG meetings, the literature searches and dissemination. The WG members did not receive any payment. The authors have no conflicts of interest to declare.

DISCLAIMER

This document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation.

The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type.

^†ESHRE pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Risk Assessment of the Increased Occurrence of Congenital Cardiac and Non-Cardiac Defects in Fetuses with a Normal Karyotype after Assisted Fertilization in Comparison to Natural Fertilization Based on Ultrasound Diagnostics

The goal of the study was to assess changes in parameters based on ultrasound examinations—these were Crown Rump Length (CRL), Nuchal Translucency (NT), Fetal Heart Rate (FHR), and Pulsatility Index for Ductus Venosus (DV-PI)—in the first trimester of pregnancy in women in which there was a natural initiation of the pregnancy due to spontaneous ovulation, women in which the pregnancy was initiated as a result of stimulated ovulation, as well as in the group in which pregnancy was achieved through the use of In-Vitro Fertilization (IVF)-assisted reproduction. A total of 1581 women became pregnant without the use of assisted reproduction methods. Out of 283 pregnancies, in 178 patients, induced ovulation was utilized. Next, 137 women had sexual intercourse and became pregnant; 41 of them became pregnant through Intrauterine Insemination (IUI) as a result of Artificial Insemination by Husband (AIH), and 13 became pregnant after Artificial Insemination by Donor (AID). The third group consisted of 105 women subjected to Controlled Ovarian Hyperstimulation (COH). In this group of pregnant women, 53 pregnancies were resultant of Intracytoplasmic Sperm Injection (ICSI), and 52 pregnancies were the result of Intracytoplasmic Morphologically selected Sperm Injection (IMSI). The obtained results did not indicate that the chosen method of fertilization or the chosen ovulation method had a statistically significant effect on the development risk of congenital heart or non-heart defects in the fetus.

Self-reported mental health status of donor sperm-conceived adults

While donor-conceived children have similar mental health outcomes compared to spontaneously conceived children, there is an inconsistency between studies investigating mental health outcomes of donor-conceived people in adulthood. This study is an online health survey that was completed by 272 donor sperm-conceived adults and 877 spontaneously conceived adults from around the world. Donor sperm-conceived adults had increased diagnoses of attention deficit disorder (P = 0.004), and autism (P = 0.044) in comparison to those conceived spontaneously. Donor sperm-conceived adults self-reported increased incidences of seeing a mental health professional (P < 0.001), identity formation problems (P < 0.001), learning difficulties (P < 0.001), panic attacks (P = 0.038), recurrent nightmares (sperm P = 0.038), and alcohol/drug dependency (P = 0.037). DASS-21 analysis revealed that donor sperm-conceived adults were also more stressed than those conceived spontaneously (P = 0.013). Both donor sperm and spontaneously conceived cohorts were matched for sex, age, height, alcohol consumption, smoking, exercise, own fertility, and maternal smoking. The increase in adverse mental health outcomes is consistent with some studies of donor-conceived adult mental health outcomes. These results are also consistent with the Developmental Origins of Health and Disease (DOHaD) phenomenon that has linked adverse perinatal outcomes, which have been observed in donor-conceived neonates, to increased risk of chronic disease, including mental health. Further work is required to reconcile our observations in adults to contrary observations reported in donor-conceived children.

Medically assisted reproduction and parent-child relationships during adolescence: evidence from the UK Millennium Cohort Study

STUDY QUESTION

Do the parent–child relationships of adolescents born after medically assisted reproduction (MAR) using the parents’ own gametes differ from those of adolescents born after natural conception (NC)?

SUMMARY ANSWER

MAR and NC families have similar parent–child relationships in terms of closeness and conflict frequency, except that MAR mothers report being closer to their children than NC mothers.

WHAT IS KNOWN ALREADY

Prior work on parent–child relationships during childhood has reported mixed findings. While some studies have documented no differences between MAR and NC families, others have shown that MAR families have greater levels of warmth and positive feelings than NC families. Evidence on parent–child relationships during the adolescent period is generally positive but is limited because of the small number of existing studies and the reliance on small samples.

STUDY DESIGN, SIZE, DURATION

This work is based on the UK Millennium Cohort Study, whose study members were born in 2000–2002. The analyses focused on Sweep 6 which was collected when cohort members were around 14 years old. We also relied on variables collected in Sweep 1, when cohort members were aged around 9 months, to account for characteristics that could confound or mediate the relationship between MAR and our outcomes. The attrition rate between Sweeps 1 and 6 was 36.7%.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The final sample consisted of 10 233 cohort members, 320 of whom were conceived with the help of MAR (3.1%). A total of six dependent variables were used to measure, when the cohort members were around 14 years old, levels of parent–child closeness and conflict, reported separately by the mother, the father and the cohort member. Linear models were used to analyse the association between parent–child relationships before and after adjustment for socio-demographic characteristics and mental health.

MAIN RESULTS AND THE ROLE OF CHANCE

Sweep 6 achieved a response rate of 76.3% of the eligible sample. The results show that, on average, MAR and NC families had similar parent–child relationships in terms of closeness and conflict frequency. The only difference was that MAR mothers reported being closer to their children than NC mothers both before (β = 0.149, P < 0.05) and after (β = 0.102, P < 0.1) adjustment for family socio-demographic characteristics and mental health.

LIMITATIONS, REASONS FOR CAUTION

The outcome variables are self-reported by each of the respondents and could be subject to social desirability bias. Second, some parents may have not reported they conceived through donor insemination, which could result in the analytical sample including a small subset of children who were not genetically related to their parents. Third, the data did not include information about whether the children were aware of their conception mode, since the Millennium Cohort Study did not collect information on MAR disclosure. Moreover, they did not allow us to study other aspects of parent–child relationships. Finally, as we observed parent–child relationships at only one moment in time; we were unable to test whether they changed over time.

WIDER IMPLICATIONS OF THE FINDINGS

The results suggest that the difficulties and the stress parents underwent to conceive through MAR did not translate into more difficult parent–child relationships during adolescence. Given the increasing number of children conceived via MAR, the finding that MAR and NC families had similar parent–child relationships in terms of closeness and conflict frequency is reassuring.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by European Research Council agreement n. 803959 (MARTE to A.G.). The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

n/a

Use of in vitro fertilization-ethical issues

This report is an ethical analysis based on both facts and values. In in vitro fertilization (IVF), there is an intricate interaction between rapid scientific development and changing societal values. In most countries, the ethical discussion is no longer on whether or not IVF in itself is ethically justifiable. Therefore, in this review, I discuss other ethical aspects that have emerged since IVF was first introduced, such as upper age limits, 'ownership' of gametes and embryos, IVF in single women and same-sex couples, preimplantatory genetic testing, social egg freezing, commercialization, public funding, and prioritization of IVF. Despite secularization, since religion still plays an important role in regulation and practices of IVF in many countries, positions on IVF among the world religions are summarized. Decision-making concerning IVF cannot be based only on clinical and economic considerations; these cannot be disentangled from ethical principles. Many concerns regarding the costs, effects, and safety of IVF subtly transcend into more complex questions about what it means to society to bear and give birth to children.

Conversation Orientation Moderates the Relationship between Information Sharing of Medically Assisted Reproduction and Child Adjustment

Parents who experienced infertility have increasingly used medically assisted reproduction (MAR) to add children to their families over the past few decades. These parents will need to decide if they will tell their children about being conceived using MAR. Although MAR information sharing operates within family contexts, little is known about the role of conversation orientation-one family contextual factor-in child outcomes associated with MAR information sharing in middle childhood. Derived from the Family Communication Patterns Theory, this study proposes that conversation orientation moderates the associations between MAR information sharing and children's psychosocial adjustment. This proposal was tested using a sample of 81 6- to 12-year-old MAR-conceived children from 55 families and a structured observational measure of conversation orientation. Multiple regression analyses showed that MAR information sharing interacted with conversation orientation to influence children's behavioral and attention problems but not emotional problems. In families with high conversation orientation, MAR information sharing was not significantly associated with children's behavioral and attention problems. In families with low conversation orientation, MAR information sharing was significantly associated with an increase in children's behavioral and attention problems. Results of this exploratory study demonstrate the potential significance of general communication orientation in understanding child outcomes of MAR information sharing and highlight the needed family context nuances in MAR research.

Intracytoplasmic sperm injection for male infertility and consequences for offspring

Intracytoplasmic sperm injection (ICSI) has become the most commonly used method of fertilization in assisted reproductive technology. The primary reasons for its popularity stem from its effectiveness, the standardization of the procedure, which means that it can easily be incorporated into the routine practice of fertility centres worldwide, and the fact that it can be used to treat virtually all forms of infertility. ICSI is the clear method of choice for overcoming untreatable severe male factor infertility, but its (over)use in other male and non-male factor infertility scenarios is not evidence-based. Despite all efforts to increase ICSI efficacy and safety through the application of advanced sperm retrieval and cryopreservation techniques, as well as methods for selecting sperm with better chromatin integrity, the overall pregnancy rates from infertile men remain suboptimal. Treating the underlying male infertility factor before ICSI seems to be a promising way to improve ICSI outcomes, but data remain limited. Information regarding the health of ICSI offspring has accumulated over the past 25 years, and there are reasons for concern as risks of congenital malformations, epigenetic disorders, chromosomal abnormalities, subfertility, cancer, delayed psychological and neurological development, and impaired cardiometabolic profile have been observed to be greater in infants born as a result of ICSI than in naturally conceived children. However, as subfertility probably influences the risk estimates, it remains to be determined to what extent the observed adverse outcomes are related to parental factors or associated with ICSI.

Experiences and psychological outcomes of the oocyte donor: a survey of donors post-donation from one center

PURPOSE

To assess the experiences and psychological outcomes of oocyte donors from one fertility center.

METHODS

An anonymous survey was distributed via a secure email to 161 donors who underwent oocyte donation-anonymous, directed/known, and recruited agency-between January 2008 and January 2019 at the NYU Langone Fertility Center.

RESULTS

Thirty-six donors completed the survey with the majority between 2 and 10 years since donation. Respondents reported a high prevalence of psychiatric symptoms or diagnoses post-donation. The majority of donors reported positive thoughts and feelings toward their donation process as well as to the knowledge of children born from their donation. Negative comments about donation were in the minority but focused on unexpected aspects about the process or outcome. Based on qualitative analysis, thoughts about family or "family-oriented thoughts" were the most frequent theme in respondent comments. 62.5% of respondents reporting that they would be open to identity-disclosure or open donation after experiencing the process.

CONCLUSIONS

Despite a high reported prevalence of psychiatric symptoms, the majority of respondents felt positively about the donation experience as well as the prospect of open donation or identity-disclosure post-donation. Further research on long-term psychological outcomes, related to all aspects of donation, is important as the counseling and informed consent of oocyte donors continues to evolve. These data will be particularly important with regard to the aspect of disclosure, both planned and unplanned, in the modern era of electronic information sharing.

Challenging Oedipus in changing families: Gender identifications and access to origins in same-sex parent families created through third-party reproduction

Socio-cultural changes and advancements in assisted reproduction over the past 40 years have led to a rise in new family forms, including same-sex parent families formed through donor insemination or surrogacy, wherein the loving couple does not coincide with the generative couple and the parents do not embody sexual difference. Can we still understand the gender identification processes and the path of accessing one's origins through the lens of the Oedipal complex? In keeping with the Freudian concepts of "psychosexuality," "primal scene" and "family romance," as well as the more recent developments in psychoanalysis, attachment theory and infant research, this article aims at revisiting the Oedipal "complex" as Oedipal "complexity," which may apply irrespective of parents' anatomical characteristics. However, this "complexity" does not renounce parents' bodies and sexuality as important to children's development. Maintaining the concept of third following the parental couple, and position within generations in the idea of Oedipal complexity, the authors suggest that a child's development pathways will depend not only on the intersection of the child's Oedipal and pre-Oedipal levels, but also on the parents' early relational events and internalisation of their own parental figures, which are not necessarily pre-determined by their gender or sexual orientation.

The perspectives of adolescents conceived using surrogacy, egg or sperm donation

STUDY QUESTION

What are the perspectives of adolescents conceived using surrogacy, egg or sperm donation regarding their conception and the third party involved?

SUMMARY ANSWER

The majority of adolescents described feeling indifferent about their conception, and yet simultaneously reported an interest in the third party involved, or were in contact with them.

WHAT IS KNOWN ALREADY

There is an assumption that children conceived through reproductive donation will feel negatively about their origins in adolescence. However, little is known about the views of adolescents who have been conceived through different types of reproductive donation.

STUDY DESIGN, SIZE, DURATION

Forty-four adolescents, all of whom had been told about their conception in childhood, participated in a semi-structured interview as part of the sixth phase of a longitudinal, multi-method, multi-informant study of assisted reproduction families in the UK.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All adolescents were aged 14 years, had been conceived using surrogacy (n = 22), egg donation (n = 13) or sperm donation (n = 9) to heterosexual couples, and varied in terms of their information about, and contact with, the third party involved in their conception. Semi-structured interviews were conducted in participants' homes. Interviews were analysed qualitatively to determine adolescents' perceptions of their conception, and their thoughts and feelings about the surrogate or donor involved.

MAIN RESULTS AND THE ROLE OF CHANCE

Adolescents were found to feel positive (n = 7), indifferent (n = 32) or ambivalent (n = 5) about their conception. Amongst adolescents not in contact with the surrogate or donor, most were interested (n = 16) in the surrogate or donor, and others were ambivalent (n = 4), or not interested (n = 6) in them. Adolescents in contact with the surrogate or donor expressed positive (n = 14), ambivalent (n = 1) or negative (n = 1) feelings about them.

LIMITATIONS, REASONS FOR CAUTION

Of 56 adolescents invited to take part in the study, 47 consented to take part, giving a response rate of 84%. It was not possible to obtain information from adolescents who do not know about their conception.

WIDER IMPLICATIONS OF THE FINDINGS

The findings contradict the assumption that children conceived through reproductive donation will feel negatively about their origins in adolescence and suggest that it may be helpful to draw a distinction between adolescents' feelings about their conception in general, and their feelings about the surrogate or donor in particular.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Wellcome Trust [097857/Z/11/Z]. The authors have no conflicts of interest to declare.

The psychosocial health of children born after medically assisted reproduction: Evidence from the UK Millennium Cohort Study

The increasing number of children conceived through medically assisted reproduction (MAR, including IVF/ICSI, intrauterine insemination and ovulation induction) has led to concerns about the potential negative effects of fertility treatments on children’s psychosocial health. Some studies suggest that MAR children might be at higher risk of developing psychosocial problems when they enter adolescence. However, very few studies have examined the development of MAR children after childhood. Moreover, even though parental socio-economic characteristics are known to be highly correlated with children’s psychosocial development, most existing studies on the outcomes of MAR children did not take into account the selective characteristics of the couples who accessed fertility treatments. Using data from waves 1–6 of the UK Millennium Cohort Study, we compare the psychosocial health, as measured by the Strengths and Difficulties Questionnaire, of MAR children to that of naturally-conceived (NC) children, up to and including the age of 14. We control for a wide range of time-constant child and parental characteristics that might confound the association between MAR and the psychosocial health of children. Results from multilevel random intercept models that do not account for parental characteristics show that MAR children have a lower incidence of psychosocial problems than NC children. In models that control for parental characteristics, MAR children are found to have a higher incidence of psychosocial problems than NC children at age three, which suggests that high parental resource levels both explain the advantage of MAR children in unadjusted models, and mask the potentially adverse effects of MAR at young ages. However, in the fully adjusted models in which MAR children have more psychosocial problems at young age, the differences with respect to NC children decrease with age and become statistically and substantively negligible by end of follow-up at age 14. This result suggests that the use of MAR does not increase children’s risk of having psychosocial problems at the onset of adolescence.

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We compare Medically Assisted Reproduction (MAR) and naturally conceived children.

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MAR children experience lower levels of psychosocial problems than NC children at all ages from 3 to 14.

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The selective characteristics of MAR parents explain the observed difference.

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Net of parental characteristics, young MAR children have higher levels of psychosocial problems, but the gap decrease and eventually converges by age 14.

Ethics of stem cell-derived gametes made in a dish: fertility for everyone?

A timely and thoughtful discussion of the ethical challenges and societal impacts presented by the recent reports demonstrating the successful in vitro generation of functional gametes from somatic and pluripotent stem cells.

The Role of professional facilitators in cross-border assisted reproduction

The operations of those who facilitate travel across international borders for access to assisted reproduction are little understood. Within the broader field of research into medical travel facilitators, most empirical studies have addressed websites and promotional materials, with few qualitative investigations of individuals who are service providers. The research presented here centres on interviews with 23 professionals facilitating cross-border assisted reproduction. This study sought to understand how facilitators and service providers operate within a professional framework, examining their understanding of the ethical limits on their roles within a largely unregulated and rapidly evolving international 'marketplace'. Broadly, participants trusted in the market to 'find its own level', such that unscrupulous players would not succeed because others would not refer to, or work with, them. In instances where a clear risk to the health of reproductive contributors or to the well-being of future children was perceived, participants understood their own ethical duty to be limited to service denial or withdrawal of participation. Among the eight facilitators who were not legal or medical professionals, there was a striking commonality, in that all had personal experience of assisted reproduction, both as patients and as reproductive contributors. Within this group, and particularly among the six women who directly 'matchmade' arrangements between intended parents, egg donors and surrogates, was a strong sense of 'embodied' expertise and claims to ethical practice based upon that expertise.

The (Re) Production of the Genetically Related Body in Law, Technology and Culture: Mitochondria Replacement Therapy

Advances in medicine in the latter half of the twentieth century have dramatically altered human bodies, expanding choices around what we do with them and how they connect to other bodies. Nowhere is this more so than in the area of reproductive technologies (RTs). Reproductive medicine and the laws surrounding it in the UK have reconfigured traditional boundaries surrounding parenthood and the family. Yet culture and regulation surrounding RTs have combined to try to ensure that while traditional boundaries may be pushed, they are reconstructed in similar ways. This paper looks at the most recent RT to be permitted in the UK, mitochondria (mtDNA) replacement therapy (MRT). Despite controversial media headlines surrounding the technique, MRT is in fact an example of how science and regulation seek to expand models of traditional relatedness in a way that doesn’t challenge the existing order. Yet, like other RTs, while attempts are made to ensure it doesn’t push traditional boundaries too far, fissures and inconsistencies appear in law and culture, which give interesting insights into how genetics, parentage and identity are being mediated in new but familiar ways.

Health and functioning of adolescents conceived by assisted reproductive technology

OBJECTIVE

To evaluate the general health, mental health, and cognitive ability of assisted reproductive technology (ART)-conceived adolescents.

DESIGN

A nested case-control study within a historic cohort.

SETTING

Not applicable.

PATIENT(S)

A total of 253 ART-conceived adolescents born between 1982 and 1993 and 253 matched references according to birth year, gender, and the high-school they attended.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Medical and psychiatric diagnoses, and cognitive ability recorded at the military preinduction screening (ages 16-17 years) and doctor's appointments throughout the military service.

RESULT(S)

No differences were detected in general and mental health of ART adolescents or cognitive ability, compared with the reference group. Similar results were obtained after stratification for gender and singleton births. The ART adolescents had fewer cases of discharge from military service due to health reasons (4% vs. 8.3%). Follow-up during the military service revealed that male ART adolescents had significantly more doctor's appointments compared with the reference group (23.80 ± 15.59 vs. 19.95 ± 13.79).

CONCLUSION(S)

Our preliminary results provide reassurance that in the long-run health and functioning of ART-conceived adolescents is not compromised. Further studies with larger cohorts are needed to confirm these results.

Disclosure of donor conception in the era of non-anonymity: safeguarding and promoting the interests of donor-conceived individuals?

This article responds to a debate article published in Human Reproduction earlier this year. In that article, the authors suggested that parents should be encouraged to disclose the use of donor gametes to their children given rapid and widespread advances in genetic testing and sequencing. However, there is an urgent need to engage with the assertion that in this context, telling children about their donor conception both safeguards and promotes their interests, particularly if such disclosure is motivated by parents' anxieties about accidental discovery. Disclosure that is motivated by the notion of non-anonymity may also encourage parents to share misinformation about donors and encourage their children to have unrealistic expectations. Fertility professionals must remain mindful of these outcomes when discussing disclosure and the future implications of increasing access to genetic information with both prospective and current parents. It is strongly advised that future discussions about the end of donor anonymity are not conflated with the debate on disclosure.

The ethical challenges of the clinical introduction of mitochondrial replacement techniques

Mitochondrial DNA (mtDNA) diseases are a group of neuromuscular diseases that often cause suffering and premature death. New mitochondrial replacement techniques (MRTs) may offer women with mtDNA diseases the opportunity to have healthy offspring to whom they are genetically related. MRTs will likely be ready to license for clinical use in the near future and a discussion of the ethics of the clinical introduction of MRTs is needed. This paper begins by evaluating three concerns about the safety of MRTs for clinical use on humans: (1) Is it ethical to use MRTs if safe alternatives exist? (2) Would persons with three genetic contributors be at risk of suffering? and (3) Can society trust that MRTs will be made available for humans only once adequate safety testing has taken place, and that MRTs will only be licensed for clinical use in a way that minimises risks? It is then argued that the ethics debate about MRTs should be reoriented towards recommending ways to reduce the possible risks of MRT use on humans. Two recommendations are made: (1) licensed clinical access to MRTs should only be granted to prospective parents if they intend to tell their children about their MRT conception by adulthood; and (2) sex selection should be used in conjunction with the clinical use of MRTs, in order to reduce transgenerational health risks.

Regulating Gamete Donation in the U.S.: Ethical, Legal and Social Implications

This article explores the practice of gamete donation in the U.S. having in mind the larger question of what do we as a society owe children born as a result (donor-conceived children). Do recipient-parents have a duty to tell their donor-conceived child about his/her genetic origins? Should the identity of the donor be disclosed or remain anonymous? Does the child have a right to know her conception story and to receive information, including identifying information, about the donor? Furthermore, if a donor-conceived child has a right to know, who has the duty to tell her/him about it? The Article underscores the ethical, legal and social dilemmas that arise, comparing and contrasting with international developments in this arena. It highlights the market-based and more specific medical justifications for regulating this field, explores the emerging so-called right of the child to know his/her genetic origins (“the right to know”), and considers the challenges such a right evokes to existing legal culture and principles of medical ethics in the U.S. as well as other broader societal implications of such a right.

Gamete donation, information sharing and the best interests of the child: an overview of the psychosocial evidence

This paper overviews key empirical findings from social science research regarding the impact of gamete donation on child wellbeing. In particular, the paper addresses current regulatory debates concerning information sharing and the best interests of the child by considering psychosocial aspects of telling--or not telling--children about their donor conception and the identity of their donor. The paper identifies three core sets of empirical, ethical and policy concerns underpinning these debates relating to (i) the psychosocial impact of gamete donation per se on child wellbeing, (ii) the psychosocial impact of parental disclosure decisions on child wellbeing, and (iii) the psychosocial implications of donor identification for donor-conceived offspring. The paper illustrates how these concerns are framed by ideas about the significance-or not-of 'genetic relatedness'; ideas which have come to the fore in contemporary discussions about the potential consequences of donor-conceived individuals gaining access to their donor's identity. By drawing together research findings that may be pertinent to the regulation of gamete donation and information sharing, a further aim of this paper is to explore the potential use and misuse of empirical 'evidence' in ethical and policy debates. Whilst this paper starts from the premise that psychosocial data has a vital role in grounding normative discussions, it seeks to contribute to this dialogue by highlighting both the value and limitations of social science research. In particular, the paper argues for a cautious approach to applying psychosocial evidence to ethical issues that is sensitive to the caveats and nuances of research findings and the changing cultural and regulatory context.