Artificial Insemination

Development of the Tool to Empower Parental Telling and Talking (TELL Tool): A digital decision aid intervention about children's origins from donated gametes or embryos

Objective

This study aimed to create and develop a well-designed, theoretically driven, evidence-based, digital, decision Tool to Empower Parental Telling and Talking (TELL Tool) prototype.

Methods

This developmental study used an inclusive, systematic, and iterative process to formulate a prototype TELL Tool: the first digital decision aid for parents who have children 1 to 16 years of age and used donated gametes or embryos to establish their families. Recommendations from the International Patient Decision Aids Standards Collaboration and from experts in decision aid development, digital health interventions, design thinking, and instructional design guided the process.

Results

The extensive developmental process incorporated researchers, clinicians, parents, children, and other stakeholders, including donor-conceived adults. We determined the scope and target audience of the decision aid and formed a steering group. During design work, we used the decision-making process model as the guiding framework for selecting content. Parents' views and decisional needs were incorporated into the prototype through empirical research and review, appraisal, and synthesis of the literature. Clinicians' perspectives and insights were also incorporated. We used the experiential learning theory to guide the delivery of the content through a digital distribution plan. Following creation of initial content, including storyboards and scripts, an early prototype was redrafted and redesigned based on feedback from the steering group. A final TELL Tool prototype was then developed for alpha testing.

Conclusions

Detailing our early developmental processes provides transparency that can benefit the donor-conceived community as well as clinicians and researchers, especially those designing digital decision aids. Future research to evaluate the efficacy of the TELL Tool is planned.

Alpha Test of the Donor Conception Tool to Empower Parental Telling and Talking

OBJECTIVE

To conduct an alpha test of the prototype of a digital decision aid to help parents disclose donor conception to their children, the Donor Conception Tool to Empower Parental Telling and Talking (TELL Tool).

DESIGN

Convergent mixed-methods design.

SETTING

Virtual interviews in places convenient to the participants.

PARTICIPANTS

A purposeful sample (N = 16) of nine gamete-donor and embryo-recipient parents and eight clinicians, as one parent was also a clinician.

METHODS

We conducted cognitive interviews to explore participants' perceptions about the TELL Tool prototype and observe patterns of use. The International Patient Decision Aid Standards (i.e., usability, comprehensibility, and acceptability) guided the development of the qualitative interview guide and directed the qualitative analysis. We also collected data about participants' perceptions and ratings of the helpfulness of each of the prototype's webpages regarding parents' decision making about disclosure. Descriptive statistics were used to analyze the helpfulness ratings before we merged the two data sets to optimize understanding.

RESULTS

Participants reported that the TELL Tool was a helpful digital decision aid to help parents tell their children how they were conceived. Most (93.7%) webpage rating scores indicated that the content was very helpful or helpful. The participants identified content and technical areas that needed refinement and provided specific recommendations such as adding concise instructions (usability), tailoring adolescent language (comprehensibility), and softening verbiage (acceptability).

CONCLUSION

Alpha testing guided by the International Patient Decision Aid standards was an essential step in refining and improving the TELL Tool prototype before beta testing.

Live birth, cumulative live birth and perinatal outcome following assisted reproductive treatments using donor sperm in single women vs. women in lesbian couples: a prospective controlled cohort study

Purpose

Assisted reproductive technology (ART) treatments with donor sperm have been allowed for women in lesbian relationships (WLR) since 2005 in Sweden, but for single women (SW), these became approved only recently in 2016. This study was conducted to compare the outcomes of ART treatments in SW vs. WLR.

Methods

This is a prospective controlled cohort study of 251 women undergoing intrauterine insemination (D-IUI) or in vitro fertilization (D-IVF) using donor sperm between 2017 and 2019 at the department of Reproductive Medicine, Karolinska University Hospital. The cohort comprised 139 SW and 112 WLR. The main outcomes included differences in live birth rate (LBR) and cumulative live birth rate (cLBR) between the groups. The SW underwent 66 D-IUI and 193 D-IVF treatments and WLR underwent 255 D-IUI and 69 D-IVF treatments. Data on clinical characteristics, treatment protocols and clinical outcomes were extracted from the clinic’s electronic database. The outcomes of D-IUI and D-IVF were separately assessed.

Results

The cohort of SW was significantly older than WLR (37.6 vs. 32.4 years, P < 0.001), and more commonly underwent IVF at first treatment (83% vs. 29%, P < 0.000). Conversely, WLR underwent more frequently D-IUI as a first treatment (71% vs. 17% of SW, P < 0.001) and more often in the natural cycle (89.9% vs. 70.8%, P = 0.019), respectively. There was no statistically significant difference in the main outcome LBR between the two groups, or between the two different types of treatment, when adjusted for age. Perinatal outcomes and cLBR were also similar among the groups.

Conclusions

SW were, on average, older than WLR undergoing treatment with donor sperm. No significant differences were seen in the LBR and cLBR when adjusted for age between the two groups and between the two types of treatment (D-IVF vs. D-IUI).

Trial registration

ClinicalTrials.gov NTC04602962.

Co-designing genomics research with a large group of donor-conceived siblings

BACKGROUND

Human genomics research is growing rapidly. More effective methods are required for co-design and involving people, especially those sub-populations which are inherently high interest to medical research and thus at greater risk of being exploited. This case study documents how we worked with a large group of donor-conceived siblings who share the same sperm donor father, to explore how they might want to engage with and influence any future genomic research.

METHOD

A participatory action research process was used to explore the views of a group of 18 people who knew they are donor-conceived siblings. They are part of a larger group of up to 1000 people who share the same sperm donor father but the only ones in contact with each other; it is likely that many of the uncontacted siblings are unaware of their biological father, have been unable to trace others or have died. The discussion explored views about how the group would like to be involved in future research. Five members participated in co-design; 12 completed a pre-discussion online survey; and six participated in an online discussion forum and evaluation survey. The online discussion was led by one facilitator, supported by the study team.

RESULTS

Of the 18 siblings approached in 2018, 14 participated in the co-design stages or the surveys and online discussion. Co-design informed the research process. Participants reported enjoying the overall experience of the surveys and discussion forum, which were perceived as inclusive and flexible. Most participants' views regarding the value of involvement in research changed during the process, and 'widened' about who should be involved. Participants were supportive of future research being done with the siblings group. All who completed the final survey requested to remain part of the co-design process. Other themes in the online discussion included concerns about conflicting interests and a desire for research participation to improve the situation for people affected by assisted conception. The process informed later discussions in the sibling group about participating in a self-managed biobank and informed decision making about participating in genomics research.

CONCLUSION

Findings from this study help inform ways in which people from certain sub-populations can be involved in planning and defining their participation in genomic research, particularly those that are inherently high interest to medical research and thus at greater risk of exploitation. This process provides a replicable method of involving potential participants in co-designing genomics research using online discussions, with positive outcomes. Reporting this study using 'Standardised data on initiatives (STARDIT)' to report the process allows comparison with other studies.

Gamete donors' reasons for, and expectations and experiences of, registration with a voluntary donor linking register

This paper reports on a study of the views and experiences of 21 sperm donors and five egg donors registered with UK DonorLink (UKDL), a voluntary DNA-based contact register established to facilitate contact between adults who wish to identify and locate others to whom they are genetically related following donor conception. Specifically, the paper examines donors' reasons for searching for, or making information about themselves available to donor-conceived offspring. Their expectations of registration with UKDL, experiences of being registered and finally, the experiences of those who had contacted donor-conceived offspring and other genetic relatives are investigated. While most respondents reported largely positive experiences of registration, the study found significant issues relating to concerns about donation, DNA testing, possible linking with offspring and expectations of any relationship that might be established with offspring that have implications for support, mediation and counselling. Research that puts the experiences, perceptions and interests of gamete donors as the central focus of study is a relatively recent phenomenon. This study contributes to this debate and highlights directions for future research in this area.

Predicting suitable timing for artificial reproductive technology treatment in aged infertile women

It has been widely accepted that the age of women plays a fundamental role in fecundity, and age-related fertility decline has one of the most significant and detrimental effects on the success rate of infertility treatment. Therefore, treatment cycles of non-in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment for infertile women of advanced aged have been limited due to their lack of efficacy, and they are often optimized, compared to IVF/ICSI treatment. Recent trends in infertility treatment apparently indicate that IVF/ICSI treatment, including egg donation, is frequently offered to aged women for first-line management, despite its heavy burden, but hasty IVF/ICSI treatment should be avoided, considering its socioeconomic problems. It is important to distinguish women who could conceive by non-IVF/ICSI treatment, although the optimization of non-IVF/ICSI treatment protocols remains poorly understood. This review focuses on extracting aged patients who have higher chance of conceiving with non-IVF/ICSI treatment and providing necessary and sufficient infertility treatment. After initial evaluation for fertility, including tubal factor, male factor, the presence of endometriosis and/or adenomyosis, and ovarian reserve, the outcomes of fertility treatment can be predicted to some extent in aged infertile women.

Gamete donors' expectations and experiences of contact with their donor offspring

STUDY QUESTION

What are the expectations and experiences of anonymous gamete donors about contact with their donor offspring?

SUMMARY ANSWER

Rather than consistently wanting to remain distant from their donor offspring, donors' expectations and experiences of contact with donor offspring ranged from none to a close personal relationship.

WHAT IS KNOWN ALREADY

Donor conception is part of assisted reproduction in many countries, but little is known about its continuing influence on gamete donors' lives.

STUDY DESIGN, SIZE, DURATION

A qualitative research model appropriate for understanding participants' views was employed; semi-structured interviews were conducted during January–March 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Before 1998, gamete donors in Victoria, Australia, were subject to evolving legislation that allowed them to remain anonymous or (from 1988) to consent to the release of identifying information. An opportunity to increase knowledge of donors' expectations and experiences of contact with their donor offspring recently arose in Victoria when a recommendation was made to introduce mandatory identification of donors on request from their donor offspring, with retrospective effect. Pre-1998 donors were invited through an advertising campaign to be interviewed about their views, experiences and expectations; 36 sperm donors and 6 egg donors participated.

MAIN RESULTS AND THE ROLE OF CHANCE

This research is unusual in achieving participation by donors who would not normally identify themselves to researchers or government inquiries. Qualitative thematic analysis revealed that most donors did not characterize themselves as parents of their donor offspring. Donors' expectations and experiences of contact with donor offspring ranged from none to a close personal relationship.

LIMITATIONS, REASONS FOR CAUTION

It is not possible to establish whether participants were representative of all pre-1998 donors.

WIDER IMPLICATIONS OF THE FINDINGS

Anonymous donors' needs and desires are not homogeneous; policy and practice should be sensitive and responsive to a wide range of circumstances and preferences. Decisions made to restrict or facilitate contact or the exchange of information have ramifications for donors as well as for donor-conceived people.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Victorian Department of Health. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Sperm donor recruitment, attitudes and provider practices--5 years after the removal of donor anonymity

STUDY QUESTION

Has the change in donor anonymity legislation in UK affected the recruitment of men wanting to be sperm donors and also affected the attitudes of the practitioners who provide donor sperm treatment?

SUMMARY ANSWER

We have performed fewer IUI and IVF treatments using donor sperm following the change in legislation in April 2005 than before. However, we have seen an overall increase in men wanting to donate their sperm, including a small increase in men from ethnic minorities.

WHAT IS KNOWN ALREADY

Sweden, which removed donor anonymity in 1985, had an initial drop in men wanting to donate and then 10 years later started to have an increase. The Human Fertilisation and Embryology Authority (HFEA) and other studies in the UK have shown an overall downward trend, but have not been able to compare large time scales either side of the change in legislation.

STUDY DESIGN, SIZE, DURATION

This was a retrospective descriptive study that looked at all men who approached the clinic between the years 2000 and 2010, i.e. 5 years either side of the change in legislation (April 2005). Overall, we had 24 men wanting to be donors prior to the rule change and 65 men after the rule change. We also investigated the total number of all treatments with donor sperm, and this included a total of 1004 donor sperm treatments prior to the change in legislation and 403 donor sperm treatments after the change in legislation.

PARTICIPANTS, SETTING, METHODS

The study was set in an NHS IVF clinic in South East London. We compared the indicators of service provision, provider practices and donor attitudes, in the period between April 2000 and March 2005 (Group A) with those between April 2005 and March 2010 (Group B), i.e. 5 years either side of the change in legislation.

MAIN RESULTS

There were 875 IUI treatments and 129 IVF or ICSI treatments in Group A and 325 IUI and 78 IVF/ICSI treatments in Group B with the use of donor sperm, of which, 11.9% (119 out of 1004) in Group A and 39.5% (159 out of 403) in Group B were with donor sperm recruited by our unit. The clinical pregnancy rate per cycle of treatment in Group A was (86 out of 875) 9.8% for IUI and (27 out of 129) 20.9% for IVF/ICSI and in Group B (32/325) 9.8% and (28 out of 78) 35.9%, respectively. There was a sharp yearly fall in donor sperm treatments from 2004. Twenty-four men were screened in Group A, of which 18 (75.0%) were recruited for long-term storage and 12 (50%) were registered as donors with the HFEA when the sperm was used, whereas in Group B, 65 men were screened, 53 (82.0%) were recruited and 24 (36.92%) were registered as donors. Six (24.0%) men in Group A failed in screening because of poor semen analysis when compared with 9 (13.8%) men in Group B. The majority of post-recruitment dropouts were because of loss of follow-up or withdrawal of consent. More donors in Group A were white (92.0 versus 77.0%) and born in UK (92.0 versus 68.0%) when compared with those in Group B. Donors in Group B were more likely to be single (46.0 versus 4.0%) and to have informed their relevant partner of donation (71.0 versus 54.0%) when compared with those in Group A. 83.0% of donors in Group A were heterosexual when compared with 69.0% in Group B. The primary reason for donating in both groups of potential donors was 'wanting to help' (46.0% 'altruistic donors' in Group A versus 72.0% in Group B). Fewer donors in Group B (37%) had specific restrictions about the use of their sperm when compared with 46.0% in Group A.

LIMITATIONS, REASONS FOR CAUTION

As this was a retrospective study, there is a chance for the introduction of bias.

WIDER IMPLICATIONS OF THE FINDINGS

We have shown that despite no active in-house recruitment procedures, we are managing to recruit more potential sperm donors after the change in UK legislation, and we are able to meet the demand for treatments with in-house recruited donor sperm that is a reassuring finding for donor sperm treatment services in the wider UK.

FUNDING/COMPETING INTERESTS

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

Semen donors' curiosity about donor offspring and the barriers to their knowing

The article reports qualitative research findings which explored the meanings of kinship and genetic knowledge of fifteen pre-1990 semen donors in the UK. This is presented in the context of public and academic debates about the regulation of access to genetic information, genetic information as intellectual property and kinship knowledge, and the multiple ownership of genetic information. Semen donors in the UK traditionally were expected to take no interest in what became of their donations and those who did were considered to be unsuitable as donors. However, the present research reveals that men who donated in the past hold varied attitudes, including curiosity about how donor offspring have fared and what they look like. Whilst some donors would welcome direct contact with donor offspring, there are practical and emotional obstacles to satisfying their curiosity. Donors' views reflect the varied understandings in the UK about the implications of genetic relatedness and the time and energy required to maintain and sustain relationships.

Artificial insemination and eugenics: celibate motherhood, eutelegenesis and germinal choice

This paper traces the history of artificial insemination by selected donors (AID) as a strategy for positive eugenic improvement. While medical artificial insemination has a longer history, its use as a eugenic strategy was first mooted in late nineteenth-century France. It was then developed as 'scientific motherhood' for war widows and those without partners by Marion Louisa Piddington in Australia following the Great War. By the 1930s AID was being more widely used clinically in Britain (and elsewhere) as a medical solution to male infertility for married couples. In 1935 English postal clerk, Herbert Brewer, promoted AID (eutelegenesis) as the socialization of the germ plasm in a eugenic scheme. The next year Hermann Muller, American Drosophila geneticist and eugenicist, presented his plan for human improvement by AID to Stalin. Some twenty years later, Muller, together with Robert Klark Graham, began planning a Foundation for Germinal Choice in California. This was finally opened in 1980 as the first practical experiment in eugenic AID, producing some 215 babies over the twenty years it functioned. While AID appeared to be a means of squaring a eugenic circle by separating paternity from love relationships, and so allowing eugenic improvement without inhibiting individual choice in marriage, it found very little favour with those who might use it, not least because of a couple's desire to have their 'own' children has always seemed stronger than any eugenic aspirations. No state has ever contemplated using AID as a social policy.

The invisible man. Artificial insemination by donor and the legislation on donor anonymity: a review

Until recently, sperm donors have remained anonymous under the 1990 Human Fertilisation and Embryology Act. There has been a distinct international trend towards allowing children access to identifying information about their donor. The UK has followed and, subject to parliamentary approval, children born by donations made after 1 April 2005 will be legally entitled to information revealing the identity of their donor. The lifelong well-being of the child created must be the prime consideration in any reform of the law.

Gamete donation and anonymity: should offspring from donated gametes continue to be denied knowledge of their origins and antecedents?

This paper presents the case for a change from the current practice of anonymity and secrecy in the use of donated gametes in medically assisted conception. It does so by describing history of the practice, various committees of enquiry over the years, their recommendations for consideration of the children created and the need for follow-up of the outcome; presenting the evidence from outcome studies both about child development and family relationships where secrecy is maintained about the child's origin and those where the practice is openly to acknowledge their origins. This is followed by an analysis of the experience and views of these children once they are adults. In discussion of the composite findings recurring themes emerge. From this it is concluded that offspring from donated gametes should not continue to be denied knowledge of their origins and antecedents. In the public debate, four schools of thought are identified. Possible practical scenarios to implement change are discussed. This paper argues that the fundamental issue regarding any of these remains-that priority in decision-making should be the lifelong well-being of the children being created.

Gamete donation and anonymity: the ethical and legal debate

The British government is currently considering whether to review the law on information provision for donor offspring. This paper therefore provides an overview of the current international legal situation relating to donor anonymity and a review of the key arguments and evidence on both sides of the debate. While the British government is considering all aspects of information giving, both identifying and non-identifying donor information, this paper will focus on the most contentious issue: the provision of information that would identify the donor. The current legal situation in the UK and internationally is examined, drawing attention to a possible international trend towards more information giving. The evolution of the present British system is outlined and it is asked whether some of the concerns and values that gave rise to the practice of anonymous donation are still relevant today. Looking at the concept of a child's right to know their biological identity it examines the possible basis of such a right and its potential conflict with the perceived interests of the child's parents. Finally, some of the practical obstacles to non-anonymous donation are evaluated. The paper concludes that a review of the British law is both timely and desirable.

To tell or not to tell--what parents think about telling their children that they were born following donor insemination

Pioneering legislation regarding donor insemination was introduced in Sweden in 1985. The law gives the child, upon reaching sufficient maturity, the right to obtain information about the donor and his identity. One hundred and forty-eight Swedish couples with children conceived through donor insemination after the law was introduced have answered questions about disclosure and donation in a questionnaire. This article addresses the reasoning employed by individual couples in their decision whether or not to inform the children about their origin. Parental reflections on their decision and the children's reactions to receiving this information are also presented. Five categories of parental arguments are reported. These included 'reasons to tell', 'reasons not to tell', 'reasons why the question about telling or not would not be answered at all', 'inconclusive types of reasoning, that can still influence the fundamental decision' and 'context-dependent reasons associated with actual circumstances'. Through this meta-classification of arguments it was possible to identify clues to how professionals could facilitate parental decision-making and promote disclosure. Parents who had informed their children did not regret their decision. All of the parents who responded to the question of whether it had been beneficial to the child to tell answered 'yes'.

Spontaneous abortion incidence in the treatment of infertility

Analysis of published series indicates that, irrespective of the method of data collection, close agreement exists on empirically derived incidences of spontaneous abortion in North American populations, provided that age, previous abortion history, and gravidity are controlled. The normal incidence of clinically apparent abortion among first pregnancies in women under age 30 years is in the range 8.3% to 11.0%. A comprehensive analysis of published series on pregnancies after infertility treatment indicates that only three therapeutic methods are attended by an abortion incidence that approaches this asymptote: ovulation induction with bromocriptine in hyperprolactinemic anovulation (11.8%; n = 1,233 pregnancies); artificial insemination with donor semen for azoospermia (11.4%; n = 326 first pregnancies); and operation for endometriosis (9.3%; n = 768 pregnancies). Abortion incidences accompanying other modes of therapy are higher. Because increased abortion incidence is not generally recognized as a specific reproductive difficulty in infertile couples, as are the other two: i.e., refractory infertility despite technically adequate therapy and ectopic pregnancy, plausible physiologic mechanisms for abortions in specific categories of disease or treatment type are described and discussed in detail. Moreover, abortion incidence is proposed to be a sensitive and objective parameter with which to assess distortions in human reproductive physiology, especially when competing methods of infertility treatment have overall pregnancy outcomes that are thought to be similar.

Artificial insemination homologous and its role in the management of infertility

Fifty-seven cases of homologous artificial insemination (AIH) were reviewed as well as the reason for performing the insemination. Three patients had AIH because of impotence, and two conceived. Twenty-nine patients whose husbands had sperm counts of less than 40 million/ml had AIH combined with split ejaculates, and seven (24.1%) became pregnant. Twenty-five patients had AIH because of persistent, unexplained, poor postcoital tests despite a normal semen picture, and eight (32%) became pregnant.