Sperm Donation: Implications of Canada’s Assisted Human Reproduction Act 2004 for Recipients, Donors, Health Professionals, and Institutions

BACKGROUND

On April 22, 2004, the Assisted Human Reproduction Act came into force, prohibiting the purchase of sperm or eggs from donors in Canada. In response to the concerns of medical professionals and some consumers that prohibiting payment would lead to a decline in the number of gamete donors, Health Canada commissioned research on altruistic donor recruitment and recruitment strategies.

METHODS

Twenty-two studies of sperm donors were located and their findings reviewed. The studies spanned 23 years (1980-2003), were undertaken in a range of countries, and were chosen on the merit of their relevance to the development of recruitment strategies within a policy of altruistic sperm donation. Observations were derived from assessing and comparing the purposes, findings, and implications of the 22 studies.

RESULTS

Payment for providing sperm was made in all but three studies, although participants in 15 studies indicated clearly that their motivations were primarily altruistic. Observations indicate that men who are more willing to be identified to offspring in the future share demographic characteristics, such as age and parental status, with those who are prepared to donate altruistically. These characteristics appear to be a factor in motivation to donate altruistically.

CONCLUSION

The studies show that there are men who are prepared to donate sperm without financial payment. The findings suggest that a change is required in the culture of sperm donation, specifically the adoption of a new approach to donor recruitment.

Bioethics for clinicians: 26. Assisted reproductive technologies

Assisted reproductive technologies (ARTs) can be very helpful for certain patients, but ethical concerns have been raised about the inherent nature of specific techniques and the contexts in which many techniques are used. Physicians play important roles in supporting those who wish to become parents and in educating patients about impediments to fertilization and way to promote conception. We discuss various ethical issues surrounding ARTs, including family relationships, informed choice, gender issues, embryo status and the commercialization of reproduction, as well as legal and policy issues. We examine the empirical evidence of the effectiveness of ARTs and suggest ways to approach ARTs in practice.

Does withholding gonadotrophin administration prevent severe ovarian hyperstimulation syndrome?

Withholding gonadotrophin administration (coasting) may prevent severe ovarian hyperstimulation syndrome (OHSS). To ascertain the effectiveness of this protection a cohort of 252 consecutive in-vitro fertilization (IVF) or IVF with intracytoplasmic sperm injection (ICSI) cycles was studied. Twenty women with exaggerated response were treated with coasting. Despite coasting, four patients developed severe OHSS requiring hospitalization. Two of these four patients also required paracentesis. Multiple regression analysis in coasting cycles revealed severe OHSS was related to youth, number of oocytes retrieved and serum oestradiol prior to human chorionic gonadotrophin (HCG). Risk of developing severe OHSS was multifactorial and not necessarily prevented by withholding gonadotrophin.

Cumulative pregnancy rates and pregnancy outcome after in-vitro fertilization: > 5000 cycles at one centre

Cumulative pregnancy rates and pregnancy outcome analysis are useful methods for advising an infertile couple of the probability of in-vitro fertilization (IVF) success. All 5209 IVF cycles in 2391 couples at University Hospital, London, Ontario, Canada, over 10 years were studied. Cumulative pregnancy rates were estimated using life table analysis. The Cox proportional hazards model was used to estimate the influence of covariates. Oocyte retrieval and embryo transfer were achieved in 84 and 64% of cycles initiated respectively. There were 644 intra-uterine and 24 ectopic pregnancies (13%/cycle initiated, 15%/oocyte retrieval and 20%/embryo transfer). Cumulative pregnancy rates following six cycles were: tubal 55%, idiopathic 65%, endometriosis 60%, multifactorial 63% and male 40%. There were 68 spontaneous abortions (10.6%) and three induced abortions for congenital anomalies. The multiple gestation rate was 22%. Caesarean section and preterm delivery rates were 35 and 20% respectively, due in part to the high proportion of multiple gestations. Of 15 deliveries which resulted in stillbirths and/or neonatal deaths, 12 were multiple gestations; 18 pregnancies (3.3%) were complicated by congenital malformations. No increases in congenital malformations or spontaneous abortions were identified. Cumulative pregnancy rates were lower in cases of male infertility. Success rates did not decline with successive IVF cycles. IVF is an evolving infertility treatment.

Conversion of cycles involving ovarian hyperstimulation with intra-uterine insemination to in-vitro fertilization

Conversion to in-vitro fertilization (IVF) and embryo transfer as an alternative to cancellation was offered in 27 consecutive cycles of controlled ovarian hyperstimulation and intra-uterine insemination (IUI) cycles with excessive follicular development in patients with idiopathic infertility. IVF and embryo transfer was performed in 25 cycles, resulting in 13 pregnancies (52%), with 22% of couples having at least two embryos cryopreserved. The pregnancies have resulted in one singleton and two twin births, one spontaneous abortion, and nine ongoing pregnancies (including one triplet gestation). Four patients developed severe ovarian hyperstimulation syndrome (OHSS) after IVF and embryo transfer, including two cases requiring paracentesis. Three of four OHSS patients were pregnant, resulting in live births of healthy twins, one spontaneous abortion and one ongoing singleton gestation. In two cycles a spontaneous luteinizing hormone (LH) surge occurred, preventing oocyte retrieval. For these two women, drainage of all follicles except the five most likely to fertilize (18-22 mm diameter) was performed, followed by IUI, with no pregnancies or OHSS observed. Conversion of patients from IUI cycles to IVF/embryo transfer cycles avoids cancellation of the very cycles with the best chance of achieving pregnancy. OHSS remains a problem, necessitating extensive pre-IVF counselling and post-transfer vigilance.

Transvaginal, ultrasound-guided oocyte retrieval for in vitro fertilization

As compared to laparoscopic oocyte retrieval, the trans-vaginal, ultrasound-guided technique can be performed away from a formal operating room, without general anesthesia and its attendant risks and with a significant reduction in operating time. Performed under paracervical block and minimal analgesia, transvaginal, ultrasound-guided oocyte retrieval results in a fairly easily tolerated level of pain during the procedure and very minimal residual pain postoperatively. The mean number of oocytes retrieved, fertilization and embryo transfer rates, and clinical pregnancy rates are not significantly different between the two procedures. If bleeding occurs from the vaginal puncture site, it is easily controlled with pressure. In this study, postoperative pelvic infection occurred in three patients. The above advantages and associated reduction in cost achieved with the trans-vaginal, ultrasound-guided procedure make it the current method of choice for oocyte retrieval.